(1)
Department of Neurosurgery, University of Wisconsin, Madison, WI, USA
7.1 Case Presentation
A 90-year-old male presents with a mass in the right axilla. The mass has been slowly growing over the past 8 months. He also noticed difficulty with raising the right arm above his head. PMH significant for end-stage renal disease on dialysis. Review of systems is significant for unintentional weight loss.
The mass is on the medial wall of the axilla, about 3 cm in diameter, firm in consistency, slightly tender, freely mobile over the chest wall from anterior to posterior with limited mobility craniocaudally.
Fig. 7.1
7.2 Questions
- 1.
What do you think the patient has?
- 2.
What studies do you want to order?
- 3.
What is the next step?
- 4.
What is the treatment?
- 5.
What is the prognosis?
Answers
- 1.
The patient has a nerve sheath tumor , probably malignant ; since there is a motor deficit and weight loss (Appendix 2). Figure 7.1. shows the mass (arrow in A) and a mild right scapular winging in (B). Usual red flags for malignancy are: severe pain, motor deficit, rapidly enlarging mass, weight loss, history of NF1 (10 % risk vs 1 % in the general population), plexiform tumors, and history of radiation. This patient has two red flags. The mass probably involves the long thoracic n due to the location, inability to elevate the arm and right scapular winging.
- 2.
MRI of the right brachial plexus .
EMG/NCS (optional) looking for neuropathy of the long thoracic n.
PET scan (optional) looking for a hot spot.
Fig. 7.2
Figure 7.2. (A) T1-weighted axial MRI , showing isointense mass (asterisk) with irregular shape. (B) There is heterogeneous enhancement with contrast. These features also suggest malignancy.Related posts:
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