LIPOSARCOMA ASSOCIATED WITH FEVER AND REVERSIBLE HEPATIC-DYSFUNCTION

A 69-year-old woman first noticed a brown patch posterior to the left ear in 1983. Although biopsy at the local clinic suggested Bowen's dis ease, the patient was referred to a hospital because of extensive invo lvement of the left auricle, A 6 x 2 cm mass was located in the left a uricle and its surface was ulcerated with partial scabbing. The mass b led easily upon mechanical stimulation (Fig, la). No abnormal laborato ry findings were observed. As an inpatient, the patient underwent tota l resection of the left auricle followed by split-thickness skin graft ing. Histologically, an epithelial tumor with a border of tumor cells facing the interstitium led to a diagnosis of basal cell carcinoma (BC C), solid type (Fig. Ib). In 1991, another mass developed on the left side of the neck and prompted the patient to seek medical advice at th is department again. A 7.5 x 8.2 cm mass was identified on the left si de of the neck associated with erythema on the surface (Fig. 2a). Need le biopsy at the outpatient department revealed a class IV mass as ass essed by Papanicolaou smear. Because of the presence of many large aty pical cells, the mass was thought to be a malignant tumor different fr om a BCC. On admission, the patient was unable to walk, because of a d aily remittent fever of 39 degrees C or more, anorexia, and dehydratio n. The fever was thought to originate from the tumor. Hematologic and biochemical tests on readmission indicated anemia (WBC 9000/mm(3); RBC 3 340 000/mm(3); hemoglobin 8.5 g/dL; hematocrit 25.9%) and elevation of transaminases (total protein 7.0 g/dL, glutamate oxalacetate trans aminase (GOT) 78 IU/dL, glutamate pyruvate transaminase (GPT) 49 IU/L, lactate dehydrogenase (LDH) 523 IU/L, ALP 644 IU/L, total bilirubin 0 .2 mg/dL, C-reactive protein (CRP) 23.3 mg/dL). These findings were in dicative of hepatic dysfunction that seemed to be secondary to tumor f ever. A biopsy was performed to obtain a definite diagnosis for the ne ck tumor. The tumor showed anisokaryosis and extensive necrosis and st ained positively with Sudan III. The histologic diagnosis was liposarc oma (Fig. 2b). A computerized scan showed extension of the tumor to th e carotid artery and jugular vein. The entire tumor was resected to im prove the patient's general condition, and to prevent pressure and dir ect invasion by the tumor to the carotid artery/jugular vein, although it did not seem to provide radical treatment. Following tumor resecti on, the exposed carotid artery/jugular vein was covered with combined musculocutaneous flaps of a trapezius and pectoralis major. Postoperat ively, the patient had relief of fever and pain associated with the tu mor. Anemia improved after blood transfusion and the transaminase leve ls returned to normal, The CRP levels were 8.6 mg/dL, 1.4 mg/dL, and 0 .0 mg/dL on postoperative days 3, 8, and 28. Radiation therapy (68 Gy) was applied to the left of the healing surgical wound. The patient sh owed a favorable postoperative course and regained her appetite. She w as discharged when she became able to walk by herself. After an uneven tful interval at home, in 1992, the patient again became unable to wal k. A complete medical examination detected metastatic tumors in the le ft temporal lobe and in the right part of the occipital lobe. A CT sca n confirmed uterine and adrenal metastases. The clinical impression wa s generalized metastases of the liposarcoma, which could not be confir med by biopsy because of the patients and her family's request. Subseq uently, the anemia progressed rapidly and marked tumor fever reappeare d. The patient died of multiple organ failure due to widespread metast asis on August 5, 1992. The tumor fever was associated with an elevati on of CRP, which was 29.2 mg/dL immediately before her death. An autop sy was not carried out because of her family's objections.