Case Presentation and Discussion
Leg Mass
Liborio I. Soledad, Jr., MD Year I Surgery Resident GSI, Department of Surgery, Philippine General Hospital 1999
Notes from the Facilitator
Note 1: The surgical resident was asked to read the self-instructional program entitled "Management of a Surgical Patient" written by the undersigned and used it as a guide to present and discuss the case. This is his second output.
Note 2: You are welcome to make comment and ask questions.
Note 3: You are invited to look at the manuscript containing my comments.
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg Facilitator
We are presented with a 36/F, who came in for a mass on her right leg. Her story dates 2 months back when she first noted a small nodule on the lateral aspect of her right leg. She ignored this and did not seek consult until it gradually increased in size. There were no associated signs and symptoms noted with the mass.
(+) 5 x 4 cm mass, hard, non-tender, non-movable, non-erythematous, lateral aspect, right leg. See illustration.
CLINICAL DIAGNOSIS
Arriving at a working diagnosis is the first thing that I must do. And in doing so, I must check and confirm if there really is a mass on her right leg. Having done so, I now try to determine the tissue of origin. A leg mass can come from any of the following tissues:
1. skin 2. muscle 3. bone 4. fat
I can say that the mass is from the skin if there are evidences of skin lesions or breaks. Looking at the patient, I see none. I can therefore say that the mass is underneath the skin and is most likely NOT a skin tumor.
I can also say that the mass may be coming from bone tissue. If so, the mass should feel bony hard. I palpate for the mass and feel that the mass is not bony hard. I can therefore say that the mass is most likely NOT bone in origin.
I have now reduced the impression to a right leg mass, underneath the skin, non-bony. I am now left with two possible tissues of origin:
1. muscle 2. fat
I can say that the mass is of adipose tissue in origin if I feel that it is soft and non-tender. The mass feels hard and is not soft as expected of a fat-containing mass. I can therefore say that the mass is most likely NOT of fat tissue in origin.
I am now left with one choice, muscle. To strengthen my guess, I try to find evidences that point to muscle as tissue of origin. The mass is underneath the skin, non-hard, non-bony, and slightly movable. On further examination, the mass seems to move with flexion of leg muscles. Satisfying these, I am more confident in saying that the mass IS most likely muscle in origin. I now go on to determine whether the mass is malignant, non-malignant, or inflammatory.
If the mass were inflammatory, it would show the classic signs of inflammation, like redness, warmth, pain, and loss of function. All of these are not found in the patient. The mass is not tender, not warm, with normal skin color, and the leg is functioning normally. Thus, the mass is most likely NOT inflammatory. The mass could either be malignant or benign. Evidences that point to a malignant pathology are the following: rapid growth (2 mos), hard, fixed or non-movable, young patient, and high index of suspicion. My working diagnosis now would be: Right leg mass, muscular, probably malignant. My secondary diagnosis is: Right leg mass, muscular, probably benign.
PARACLINICAL DIAGNOSTIC PROCEDURE
My next question is whether I should employ the aid of a paraclinical diagnostic procedure. This would confirm or make my diagnosis more clear. This would all depend on my mode of treatment. If confirming my diagnosis would affect my treatment of choice, then I have to make use of a diagnostic procedure. Reviewing the case, mode of tumor removal would be different in a benign as compared to a malignancy. I therefore decide in using added assistance in diagnosis.
Choosing which diagnostic procedure comes next. What I need is a cytologic/histologic aid. Most cost-effective would be a Fine-needle aspiration of the mass. This would give us information as to a tissue source and whether the mass is malignant or not. Radiologic examinations would be a non-priority. An incisional biopsy would give us a higher yield but looking at the mass, it would need extirpation eventually. An FNAB was done in the patient with the following findings: Spindle cell carcinoma.
My choice of diagnostic procedure has now confirmed my diagnosis. My working diagnosis now would be: Spindle cell carcinoma, right leg.
TREATMENT
The next step is deciding or choosing the appropriate mode of treatment. Given that the mass is malignant, I have no choice but to excise the mass together with an adequate margin of normal tissue - wide excision. If the mass turned out to be benign during our diagnosis, we could employ simple excision. This is the benefit obtained from doing the aspiration biopsy. An adequate margin of normal would be included in the excision to avoid local recurrences and to ensure proper and good wound healing. Providing medications would prove to be futile in this case.
PRE-OPERATIVE PROCEDURE
Having decided on the mode of treatment, I will now explain to the patient, and her relatives the entire operative procedure together with the risks and possible outcomes. This is important so the patient would feel confident and would be more prepared. Providing support psychologically and psychosocially would also be employed.
I should also be wary of the possible risks that would affect the patient. Being so, I must first screen the patient from other diseases to avoid unlikely outcomes. Securing consent must be done prior to the procedure. This is obtained most often after the patient has understood the surgical procedure. After having done so, I must secure the necessary needs so I prescribe to them and allow sufficient time for procurement.
INTRA-OPERATIVE MANAGEMENT
The patient would undergo excision of the mass, to include normal tissue around it. The incision would be elliptical to ensure adequate closure of the skin. A margin of around 2-3cm of normal tissue would be included to make sure adequate removal of malignant tissue is done. Bleeding vessels would be ligated. Would defect would be closed using absorbable sutures. Sterile dressing would be applied.
POST-OPERATIVE MANAGEMENT
Immediately post-operatively, the patient would be monitored closely wherein her vital signs would be measured on a regular basis as well as to apply wound care by observing and watching out for bleeding. Patient would be comforted with analgesics and cool environment. Once patient is stable and without anesthesia, she can be transported back to the main wards.
Once in the wards, wound care would be continued as to avoid infection. If the patient remains to be stable, she can be sent home with proper instructions regarding wound care and follow-up. It is important to educate care takers so proper wound care is done.
FOLLOW-UP
I will instruct the patient to visit on regular follow-ups to make sure proper would care is made at home. Also this would give her the chance to learn and confirm the diagnosis based on histopathologic examinations. One confirmed, proper advise and counseling can be employed.
Questions and Comments from Readers
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rjoson@pacific.net.ph
Manuscript With Facilitator's Comments GSI Case Presentation and Discussion GSI Frontpage