Challenge of treating skeletal muscle metastasis during the COVID-19 pandemic in a low-resource setting.

BACKGROUND: The authors report on an extremely rare case of skeletal muscle metastasis from primary lung cancer that involved the radial nerve and humerus, which was 'over-treated' with wide tumour resection and frozen autograft reconstruction upon misdiagnosis of sarcoma by intraoperative frozen section, amid pressure of expediting hospital care in a low-resource setting during the coronavirus disease (COVID-19) pandemic. CASE PRESENTATION: A 61-year-old male living outside Metro Manila presented with painful mass in his left distal arm during the enhanced community quarantine, and requested admission upon testing negative for COVID-19. Imaging studies suggested a diagnosis of soft tissue sarcoma involving the radial nerve and humerus, and intending to prevent nosocomial severe acute respiratory syndrome coronavirus 2infection of patient, treatment was expedited by foregoing biopsy and opting for intraoperative frozen section prior to resection. Frozen section findings suggested malignancy intraoperatively, and surgical team proceeded with wide tumour resection and frozen autograft reconstruction of the humerus using plates and screws. However, permanent sections revealed metastatic carcinoma from primary non-small cell lung cancer, with positron emission tomography (PET) scan confirming lung mass in the right apical lobe. CONCLUSION: The report concludes that establishment of a definite tumour diagnosis by final histopathological analysis is indispensable, even when planning for emergent surgery in the time of the COVID-19 pandemic.

Starry Sky Pattern in Hematopoietic Neoplasms: A Review of Pathophysiology and Differential Diagnosis.

The starry sky pattern is a distinctive histologic feature wherein a rapidly proliferating hematolymphoid neoplasm contains scattered histiocytes with abundant pale cytoplasm in a background of monomorphic neoplastic cells. The cytoplasm of these histiocytes typically contains cellular remnants, also known as tingible bodies, incorporated through active phagocytosis. Although common and widely recognized, relatively little is known about the pathophysiological underpinnings of the starry sky pattern. Its resemblance to a similar pattern seen in the germinal centers of secondary follicles suggests a possible starting point for understanding the molecular basis of the starry sky pattern and potential routes for its exploitation for therapeutic purposes. In this review, we discuss the historical, pathophysiological, and clinical implications of the starry sky pattern.