VIVA

Oncology - Investigation
15 minutes
Case 1
F, 65 y.o with pain in her right shoulder. Patient with history low energy
trauma on the right shoulder
 Questions
1. Describe the further investigation necessary for this patient
 EXAMINER’S GUIDE

Literature:
Neoplasma Tulang : Diagnosis dan Terapi
Dahlin’s Bone tumor
1. Further Investigation - Xray

• What is your interpretation : Radiographic show multiple "punched-out" lytic

lesions, skeletal survey
1. Further investigation – Bone survey

• What is your interpretation : Radiographic show multiple "punched-out" lytic lesions,

skeletal survey
1. Further investigation – Laboratory Examination
• Hb 7.1 • SGOT 40 • Cl 100
• AL 7.42 • SGPT 104 • Ca 3.71
• AE 2.6 • BUN 59 • AFP 1.8
• AT 163 • Creat 7.94 • CEA 4.28
• PPT 14.4 • GDS 112 • Ca 19-9 0.82
• INR 1.03 • LDH 139 • Ca 125 11.22
• APTT 28 • Na 133 • Ca 15-3 7.06
• Alb 3.26 • K 5.52 • Bence Jones (+)
• What is your interpretation :
• anemia
• elevated creatinine
• Hypercalcemia : present in 30% of patients due to excessive resorption of bone
• ESR often elevated
• SPEP (serum protein electrophoresis) : M spike present (50% IgG, 25% IgA)
• Urine : UPEP (urine protein electrophoresis)  may show Bence Jones proteins
1. Further investigation - Histopathology

• What is your interpretation : round plasma cells with an eccentric nucleus, prominent
nucleolus, and clock face organization of chromatin
• characteristic clear area (Hoffa clear zone) next to the nucleus represents the prominent
Golgi apparatus involved in immunoglobulin (protein) production
Case 2
F, 19 y.o with pain and mass on the left distal femur growing fast
since the last 2 months.
 Questions
1. Describe the investigation necessary for this case
 EXAMINER’S GUIDE

Literature:
Neoplasma Tulang : Diagnosis dan Terapi
Dahlin’s Bone tumor
Further Investigation - Xray

What is your interpretation :

• characteristic destructive lesion: sun-burst or hair on end pattern of matrix
mineralization
• periosteal reaction (Codman's triangle)
• Large soft tissue mass with maintenance of bone cortices
1. Further Investigation – Laboratory Examination
Hb 14.5 g/dL
AL 9.13 x10^3/µL
AT 376 x10^3/µL LDH 334 U/L
Na 140 mmol/L Fosfatase alkali 281 U/L
K 5.0 mmol/L CRP Kuantitatif 17 mg/L
Cl 97 mmol/L CEA 3.86 mg/ml
Ca 1.95 mmol/L PPT 15,5 detik
Albumin 4.72 g/dL APTT 34,4 detik
BUN 6,70 mg/dL INR 1,15
Cre 0,62 mg/dL HBsAg Non Reaktif

What is your interpretation : Elevated LDH and alkaline phosphatase may

be 2-3 times normal value
Further Investigation – CT Scan Thorax, USG
Abdomen

What is your interpretation : CT chest and USG abdomen is required at

presentation to evaluate for pulmonary and abdominal metastases
Further Investigation – MRI

What is your interpretation :

MRI must include entire involved bone to determine :
• soft tissue involvement
• neurovascular involvement
• presence skip metastases
Further Investigation – FNAB

What is your interpretation :

• tumor cells show significant atypia, and produce matrix osteoid 
• stroma cells show malignant characteristics with atypia, high nuclear to cytoplasmic ratio, and
abnormal mitotic figures