Hello doctor,
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.
Biopsy result:
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.
Vital signs:
BP 110/60 mmHg.
HR 89 bpm.
RR 20.
O2 sat 99%.
BMI 19.5.
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.