The importance of history in pediatric soft tissue swellings: a case of rhabdomyosarcoma with initial diagnosis of hemangioma

Abstract

Clinicians often encounter soft tissue swellings in children, which can be benign or malignant in nature. Significant emphasis placed on radiological findings may skew clinical judgement. This cascade often leads to overlooking other differential diagnoses and the natural history of these soft tissue masses. We discuss the case of a 2-year-old child with a swelling over her left upper back. Swelling was first noticed at 6 months old, and grew progressively larger after age of one. Two ultrasounds performed reported the mass as an infantile hemangioma. It reached a point where the child could no longer lie supine due to the huge size of the mass. MRI of the back was ordered, and findings were suggestive of a posterior chest wall soft tissue sarcoma with lung metastases. Histopathological examination of tissue obtained from trucut biopsy confirmed the diagnosis of embryonal rhabdomyosarcoma stage 4. In this scenario, the natural history of soft tissue swelling was atypical of hemangioma. However, there was lapse in clinical judgement, as radiological findings were consistent with diagnosis, not once but twice. This conglomeration of factors led to unfortunate delay in diagnosis. When faced with soft tissue swellings in children, a thorough correlation between history, clinical examination, and imaging studies required to form holistic picture, for betterment of patient outcome.