PMC10159300_01
Preoperative magnetic resonance imaging demonstrating an irregular, large bilobed T1 hypointense (a and b), T2 hyperintense (c-e), heterogeneously enhancing mass (c-e) involving the right chest wall, abutting the brachial plexus, and extending into the right neck.
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F1
MRI of his chest was performed and demonstrated a large infiltrative solid heterogeneous mass centered in deep right lateral chest wall fat with infiltration into the right lower neck region [Figures 1a-e]. The divisions and cords of the right brachial plexus approached this large lesion at the level of the mid distal clavicle, although without evidence of invasion or encapsulation [Figures 1d and e].
Intraoperative lateral decubitus positioning demonstrating free mobility of the right arm and exposure of neck and anterior (a) and (b) posterior chest wall. (c) Planned supraclavicular and infraclavicular incisions. (d) Planned axillary and posterior subscapular incisions.
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F2
After consent was obtained, approximately 2 weeks after radiation therapy, the patient was brought to the operating room and was positioned in a left lateral decubitus manner with free mobility of the arm to facilitate various exposures during different phases of the operation [Figures 2a and b]. Incisions were planned to achieve a supraclavicular, infraclavicular, transaxillary, and posterior subscapular approaches [Figures 2c and d]. A curvilinear cervical incision was made along a relaxed skin tension line, extending from the right supraclavicular fossa to the posterior neck [Figure 2a]. At this point, a descending limb of the incision between the middle and lateral thirds of the clavicle was created and extended caudally along the deltopectoral groove to allow for dissection to continue infraclavicularly [Figure 2c]. The axillary incision was carried down to the chest wall between the posterolateral border of the pectoralis major muscle and the anterolateral border of the latissimus dorsi [Figure 2c].
(a) Supraclavicular incision with mass retracted laterally, dissection flap containing spinal accessory nerve, and upper trunk (*blue loop). (b) Infraclavicular exposure with medial cord (yellow loop) lateral cord (*blue loop) and posterior cord (blue loop), and axillary artery (red loop) with underlying mass. (c) Axillary and infraclavicular incisions with proximal and distal brachial plexus exposure including musculocutaneous nerve (*blue loop) and median nerve (blue loop). (d) Posterior subscapular incision with dissection off posterior chest wall and lateral mass retraction. (e) Pathology specimen of gross tumor.
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F3
With this, the capsule of the mass was easily identified superiorly, lying between the posterior border of sternocleidomastoid (SCM) and anterior border of trapezius at its highest extent in neck [Figure 3a]. More distal plexus components were palpated and identified just deep to the fat pad [Figure 3b]. The clavipectoral fascia was incised which exposed the distal plexus elements which were dissected and separated from the mass [Figure 3b]. Once the axillary artery was found [Figure 3b], the posterior cord was identified just posterior to it and secured. Neurosurgery identified the ongoing segments of the brachial plexus, including the terminal branches [Figure 3c]. The curvilinear cervical incision was then extended posteriorly between the spinous processes and the medial border of the scapula to expose the trapezius muscle [Figure 3d]. The tumor was extremely large, lobulated, and surrounded along majority of its surface by an intact capsule [Figure 3e].
Tumor histology (a) The tumor has high cellularity and severe cytologic atypia (hematoxylin and eosin, x200 magnification). (b and c) The tumor also had focal areas with loose myxoid stroma and associated delicate vessels (hematoxylin and eosin, x100 and x200 magnification. (d) Necrosis was also present (upper left of image; hematoxylin and eosin, x100 magnification). (e) Mitotic figures were also present (center of image; hematoxylin and eosin, x400 magnification).
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F4
MFS [Figure 4]. Margins were positive at the deep and superficial aspects.