PMC8225338_01
(a): Anteroposterior and (b): lateral radiographs of the left arm showing erosion of the posterolateral cortex of the distal humerus (yellow arrows).
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Review of left arm radiographs done at another hospital shows cortical erosion of the distal humerus with periosteal elevation (Figure 1a and b), while magnetic resonance imaging (MRI) confirmed a heterogeneously enhancing intramuscular mass involving the triceps measuring 3 cm x 4 cm x 4.5 cm (Figure 2a), associated with cortical destruction of, and abnormal marrow signals in the posterolateral humerus (Figure 2b), and partial tumoural encasement of the radial nerve (Figure 2c).
T2-weighted (a): coronal, (b): sagittal and (c): axial MRI confirming a heterogeneously enhancing intramuscular mass involving the triceps (yellow arrows), measuring 3 cm x 4 cm x 4.5 cm associated with cortical erosion of posterolateral humerus and partial tumoural encasement of the radial nerve (red arrow).
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Review of left arm radiographs done at another hospital shows cortical erosion of the distal humerus with periosteal elevation (Figure 1a and b), while magnetic resonance imaging (MRI) confirmed a heterogeneously enhancing intramuscular mass involving the triceps measuring 3 cm x 4 cm x 4.5 cm (Figure 2a), associated with cortical destruction of, and abnormal marrow signals in the posterolateral humerus (Figure 2b), and partial tumoural encasement of the radial nerve (Figure 2c).
Chest radiography showing ill-defined infiltrates in the right upper lobe (red arrow).
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Our differential diagnoses included benign and malignant primary soft tissue tumours, but upon review of chest radiographs done at another hospital, we noted finding of heterogenous ill-defined opacity in the right upper lobe that was officially read as tuberculosis (Figure 3).
Intraoperative photos. (a): Tumour approached via posterolateral incision to include biopsy site, (b): with radial nerve (blue line) seen adherent to tumour (yellow arrow) during wide resection. (c): Resected tumour-bearing bone seen eroded (yellow arrow) by the soft tissue mass. (d): Resected bone free of tumoural tissues treated with liquid nitrogen using free-freezing method, then thawed, washed with distilled water and (e): fixed to humerus using plates and screws.
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We approached the tumour posterolaterally (Figure 4a), with the patient on right lateral decubitus position. Upon dissection, radial nerve was adherent to tumour and cortical bone was visibly eroded (Figure 4b). Wide bone margins were identified by C-arm guidance, and humeral segment together with involved radial nerve was included in the resection (Figure 4c). Resected tumour-bearing bone was freed of tumoural tissues then soaked in liquid nitrogen (Figure 4d), thawed, washed with distilled water and re-applied to humerus by fixation using plates and screws (Figure 4e).
Postoperative (a): anteroposterior and (b): oblique radiographs of the left arm showing stable reconstruction of the humerus with acceptable alignment.
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After the surgery, patient's left elbow was immobilised with arm sling, and postoperative arm radiographs showed stable humeral reconstruction with acceptable alignment (Figure 5a and b).
(a): Routine histologic section of tumour revealing malignant epithelial cells disposed in nests and exhibiting ill-formed glandular lumen and (b): plump epithelial cells with moderate cytoplasm seen on high-power view exhibiting nuclear atypia (black arrow), anisocytosis and prominence of nucleoli.
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Final histopathological findings of the operative sample, with immunohistochemistry study, concluded the diagnosis of metastasis of an adenocarcinoma of lung origin (Figure 6a and b).