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 disease, the patient was referred to a hospital because of extensive involvement of the left auricle. A 6 × 2 cm mass was located in the left auricle and its surface was ulcerated with partial scabbing. The mass bled easily upon mechanical stimulation (Fig. 1a). No abnormal laboratory findings were observed. As an inpatient, the patient underwent total resection of the left auricle followed by split‐thickness skin grafting. Histologically, an epithelial tumor with a border of tumor cells facing the interstitium led to a diagnosis of basal cell carcinoma (BCC), solid type (Fig. 1b). In 1991, another mass developed on the left side of the neck and prompted the patient to seek medical advice at this department again. A 7.5 × 8.2 cm mass was identified on the left side of the neck associated with erythema on the surface (Fig. 2a). Needle biopsy at the outpatient department revealed a class IV mass as assessed by Papanicolaou smear. Because of the presence of many large atypical cells, the mass was thought to be a malignant tumor different from a BCC. On admission, the patient was unable to walk, because of a daily remittent fever of 39 °C or more, anorexia, and dehydration. 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 transaminase (GOT) 78 III/ 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 indicative of hepatic dysfunction that seemed to be secondary to tumor fever. A biopsy was performed to obtain a definite diagnosis for the neck tumor The tumor showed anisokaryosis and extensive necrosis and stained positively with Sudan III. The histologic diagnosis was liposarcoma (Fig. 2b). A computerized scan showed extension of the tumor to the carotid artery and jugular vein. The entire tumor was resected to improve the patient's general condition, and to prevent pressure and direct invasion by the tumor to the carotid artery/jugular vein, although it did not seem to provide radical treatment. Following tumor resection, the exposed carotid artery/jugular vein was covered with combined musculocutaneous flaps of a trapezius and pectoralis major. Postoperatively, the patient had relief of fever and pain associated with the tumor. Anemia improved after blood transfusion and the transaminase levels 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 showed a favorable postoperative course and regained her appetite. She was discharged when she became able to walk by herself. After an uneventful interval at home, in 1992, the patient again became unable to walk. A complete medical examination detected metastatic tumors in the left temporal lobe and in the right part of the occipital lobe. A CT scan confirmed uterine and adrenal metastases. The clinical impression was generalized metastases of the liposarcoma, which could not be confirmed by biopsy because of the patient's and her family's request. Subsequently, the anemia progressed rapidly and marked tumor fever reappeared. The patient died of multiple organ failure due to widespread metastasis on August 5, 1992. The tumor fever was associated with an elevation of CRP, which was 29.2 mg/dL immediately before her death. An autopsy was not carried out because of her family's objections.