Autopsy Example 1 (Page 3)

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Clinicopathological Correlation and Diagnosis:

This 70 year-old white man was diagnosed in May 1982 at age 61 as having chronic lymphocytic leukemia. He received one intravenous injection of nitrogen mustard with good results.

In January 1983, the patient was admitted to the hospital for evaluation and his white blood count was 5200 with 55% lymph., 37% mature polymorphus, 4% monocytes and 2% eosinophils. He was asymptomatic, and his prognosis for the future was described as excellent. In November 1991, the patient was admitted to the hospital, about 18 days before his death. There the diagnosis of undifferentiated adenocarcinoma of the stomach with massive dissemination of the disease was made. The patient died on December 1,1991.

Microscopic examination showed a signet ring cell carcinoma of stomach infiltrating the muscular coat with fibroblastic proliferation and thickening of the serosa. Metastatic signet ring cell carcinoma was found in many organs (see final pathologic diagnosis) and represented massive widespread metastatic disease. Only microscopically were we able to diagnose adenocarcinoma of the right bronchus, locally invasive and infiltrating bronchial cartilage and adjacent nerves but without metastases.

Although the patient was free of any symptoms of chronic lymphocytic leukemia, sections of the liver and bone marrow showed lymphocytic leukemic infiltrates. The enlargement of the spleen (770 gm.) and lymph nodes might be due to metastatic signet ring cell carcinoma as well as to leukemic involvement.

At autopsy, this case revealed three histologically different tumors. Two of them were carcinomas: signet ring cell carcinoma of the stomach with widespread metastases and adenocarcinoma of the right bronchus with local infiltration. The third malignancy was chronic lymphocytic leukemic infiltrates without definite clinical manifestation. It is quite possible that the signet ring cell carcinoma with metastases, diagnosed in late stage of such disease, covered other slightly marked features of leukemia or adenocarcinoma of the lung.

The myelofibrosis could be secondary to metastatic signet ring cell carcinoma or the results of the previous leukemic chemotherapy or connected with leukemic involvement of the bone marrow, or all of them caused such condition.

John E Jones, MD