Document LpyV1Y331mDpMR6r36qvRVbX

Case Report ML fijikj'&L, Cor Hepatic Angiosarcoma and Bronchioloalveolar Carcinoma Induced by Fowler's Solution Micftael 1_ Kasper. MO: Lynn Scnoentiela. MO; Robert L. Strom. MO: Atti*n*o TheotoqtQe*. MO. PhO THE MEDICINAL use of Fowler's solution reached its heyday daring the Victorian age, but arsenical solu tions continued to be prescribed for dermatological conditions until the 1060s. Following intake of arsenic, in t.te patient we describe, a hepatic angiosarcoma and a bronchioloalveo lar carcinoma appeared simulta neously after a prolonged latent peri- Reoort of a Case A 67-year-old man had been well uadi seven months before bis death At that t.me he was found to have ssritea, afaoorn-.al liver function teat results, and cecreseed hepatic uptake with multiple local defects appearing on a liver-spleen isotope scan. Teats for cardnoembryunie antigen and a-fetoprotein gave negative results, and the results of a liver biopsy were not diagnostic. On referral to our hospital, he was cachectic, with scleral icterus, astaruda, : jtor hepadeua. and rales in the beat of : : right lung. He hed ascites without aodominnl organomegaly or meseee His palms and soles had hyperkeratodc pap ules. His medical history included treatment with 10 g of arsenic trioxide (Fowler's solution i for dermudtis herpetiformis ftwi me Seeoan ot Hemsratoey (Or Kaaowl mu Cteersnem ot internal Maocina (Ora Kaaew ana - iwtioaMM), Unwarasy S Umwou: anu Vie Caoartmant at 0|money (Ors SnwUWM mu Sirem) ana Sacoon at Hamaasoer` Onoatopy (Or ^taotamsaa). I lannaon Coumy Haeaal Ctntar i to Unxaraay of townrow Horn 4*0 |ttawate St St tstmaapoita MN IMS (Or Kaa"arj. a i!936 through 1942). He had a 30-packyear smoking history, but he had quit smoking ten yean before we saw him. He had been smoking two packs par week whils taking Fowler's solution. He drank one or two drinks each day. Laboratory studies disclosed the follow ing values: serum urea nitrogen, 74 mg/dL (reference range, 10 to 26 mg/dL); alkaline phosphatase. 130 mU/oL (reference range, 24 to 30 mU/mL); SCOT, 34 IU/L (reference range, 11 to 22 IU/L); total bilirubin. 82 mg/dL (reference range, up to 1-3 mg/dL); ammonia. 184 umole/L (reference range, 11 to 35 titnoie/L); albu min. 13 g/dL (reference range. 32 to 21 g/dL); prothrombin dine. 15.4 a (reference range, 10 to 132 *K partial thromboplastin time, 38.4 a (reference range, 28 to 40 a); WBCa, 14200/cn mm (reference range, 5200 to lOjOOO/cn mm): and hemoglobin. 13.7 g/dL (inference range, 14 to 18 g/dL). Hepatitis B surface antigen was nonreacdve. A. cheat roentgenogram showed a density in the base of the right lung. Because of the patient's progressiva ascites, a peritoneovenous shunt was inserted. His clinical condition deterio rated. and the hepatorenal syndrome ensued, followed by sepsis and death. At autopsy, the liver was found to be redbrown and diffusely nodular; it weighed 2.450 g. The nodularity comprised paleyellow nodules measuring 02 to 4 cm in diametsr and dark-red nodules measuring 0.1 to 02 cm in diametsr. Histopathologicaily, the tumor islands consisted of dilated sinusoids lined by anaplastic endo thelial ceils. This composition created a scaffolding pattern in which cords of hepatocytes stood out in branching arrays against a background of proliferating endothelial cells (Fig 1). These latter cells spindls shsped. with eosinophilic cytoplasm, large pleomorphic nuclei, and small nucleoli, tmmunoperoxidase stain ing for factor VTII-reiatea antigen yielded positive results. Ths lower lobe of the rtgnt lung con tained a solitary 2-cm peripheral tumor nodule. Microscopically examined, the nodule showed hbroeis and solid tumor mswoe with tall columnar ceils lining the alveoli but preserving the basic alveolar architecture i Fig 2). These cells shoerod marked anaplasia, with hyperehromatic nuclei and prominent, often multiple, eosinophilic nucleoli. Bizarre giant calls and multuucleated cells were also pres ent. These histopathologic observations were believed to be most indicative of a bronchioloalveolar carcinoma. The ceils, however, showed more anaplasia and piedmorphism than is usually seen in this typo of tumor. No other epithelial tumors were present in the patient, eliminating the possibility of a lung metastasis. There was invasion of fibrotie areas by cords of tumor cells as well aa invasion of blood vessels. Mudcarmine staining showed slight positive results. Immunoperoxidase staining for factor VIII-related antigen produced negative results. No metiitaise from either of the two tumors were found at autopsy. The splenic vein was throm bosed. The hepatic portal system was grossly normal. Comment Hepatic angiosarcomas are rare 1%tumors that make up to 3% of hepatic tumors, with approximately 200 cases reported/ The association of nonmedicinal long-term arsenic expo sure and angiosarcoma of the liver was first made by Roth in an autopsy series of Moselle vintners. Three of the 27 subjects were found at necrop- Cancers From Fowler's Solution--Kasper et si 3407 UCC 080227 FELL0 medica. | Its infli its rigo | Kxnety Hanpov I become [thought 1 with ini inti Hows! Ikh.em. V Imedian Interest ISimilar |l My hi lappiicai | patients I those [not be n proceed I iuing th | view of ' may cho may not be asket have ha specialti tnc nov out area Befort should While s< i live the Vgniui training I Wt'4 (Or 4AMA D