Patient is a 66-year-old female. She have recurrent mass in the left supraclavicular area. 15 months prior, patient noted a mass at the left supraclavicular area approximately 3x3 cm, round, hard, smooth borders, movable, nontender. No pain, no numbness, no limitations of range of motions. No consult done. Condition tolerated.
12 months prior, there was noted gradual increase in size, now approximately 12x10 cm in size, round, hard, smooth borders, movable and nontender, now associated with neck pain, headache, and limited range of motion of the left upper extremity upon abduction and flexion. Patient sought consult with a private AP. Work up and biopsy was done, and was finally managed with surgical excision. Condition tolerated.
Gross: Several irregular, white tan slightly firm tissue fragments with an aggregate diameter of 100 mm. On sectioning of fragments, it presents with a solid, smooth, gelatinous cut surface.
Micro: Shows fragments of mesenchymal lesion composed of spindle cells. There are numerous cystic areas as well as prominent blood vessels. Closer magnification of the cellular areas show serpentine, buckled nuclei which have a tendency to palisade or form piket-fence pattern, suggestive of neural differentiation. The loose cellular areas are made up of the same type of serpentine cells which are set against more myxoid background, with hemosiderin laden macrophages noted. There are several dispersed cells demonstrating nuclear pleomorphism and hyperchromasia. No mitotic figures seen.
Impression: Ancient Schwannoma.
Seven months prior, there was noted recurrence of mass at the same site of the post operative area at the supraclavicular area. No associated symptoms such as neck pain, no limitations in range and motion. No consult done. No follow up due to the ongoing pandemic. In the interim, there was noted gradual increase in size.
Two weeks prior, gradual increase in size was still noted measuring approximately 13 x 11cm in size, now associated with headache, intermittent neck pain, and limitation of motion in the left upper extremity and neck which causes inability to fully abduct and flex the shoulder and inability to fully mobilize the neck laterally. Follow up and consult was done with the private AP where MRI was done.
Past medical illness:
Non asthmatic, no maintenance medications, no food and drug allergies. S/P wide excision of supraclavicular mass.
General appearance: awake, alert, coherent, not in respiratory distress.
BP 110/60 mmHg.
HR 89 bpm.
O2 sat 99%.
Skin: warm, good turgor.
ENT: Anicteric sclearae, pale palpebral conjunctiva, pupils equally round reactive to light and accommodation, no nasoaural discharge, (+) 11 x 9 cm mass, round, smooth, fixed, nontender at the supraclavicular area, left, (+) postoperative scar over the mass.
C/L: Equal chest expansion, clear breath sounds.
CVS: Adynamic precordium, distinct heart sounds, no murmurs.
Abdomen: flabby, non distended, soft, nontender all quadrants.
Gut: (-) KPS.
Ext: no edema, strong peripheral pulses, CRT.
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Would you please try to upload MRI images?
Looking at the pathology report, they concluded the mass is Schwannoma. A schwannoma is a type of nerve tumor of the nerve sheath. It is the most common type of benign peripheral nerve tumor in adults.
Treatment options: monitoring, surgery, radiation therapy, and stereotactic radiosurgery.
Recurrence of conventional spinal schwannomas is reported in less than 5% of surgical patients. Tumor recurrence typically occurs several years after initial surgical resection and appears to be associated with subtotal tumor removal.
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I have sent the images.
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This giant T2 hyperintense mass with multiple septae and hemorrhage, MRI characteristics suggest more likely nerve sheath myxoma (neurothekeoma) or myxoid type schwannoma.
Neurothekeomas are rare, benign, superficial soft tissue tumors that most commonly occur on the head and neck. They tend to affect females more often than males. It clinically presents as a skin-colored, pink, red, or brown well-circumscribed papule or nodule.
Because of overlapping clinical presentation and histology, nerve sheath myxoma has been inadvertently included within the myxoid variant of neurothekeoma. However, neurothekeoma appears to be a separate and distinct entity from true nerve sheath myxoma. Rather than arising from peripheral nerve sheath, it has been postulated that neurothekeomas are of fibrohistiocytic derivation. While nerve sheath myxoma demonstrates immunoreactivity for S100 protein, neurothekeoma fails to react with S100 regardless of the histologic pattern.
Neurothekeoma or schwannoma is considered a benign entity. Both have a low recurrence rate with complete surgical removal.
Need to rule out malignancy.Differential diagnosis:
Neurothekeoma or myxoid type schwannoma.Treatment plan:
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