Left Supraclavicular Fossa Research Articles

Recurrent supraclavicular chylous collection and chylothorax

We report a patient in whom not only was chylothorax recurrent and resolution spontaneous, but the presenting feature was a soft tissue swelling in the left supraclavicular fossa

Obstructive jaundice. An unusual presentation of granulocytic sarcoma

A 36-year-old woman presented with obstructive jaundice, found at laparotomy to be due to a granulocytic sarcoma in the head of the pancreas. Six months later she developed lymphadenopathy in the left supraclavicular fossa. In spite of chemotherapy containing cytarabine and vincristine, she developed acute myeloid leukaemia (French-American-British [FAB] type M4) 16 months after the onset of her illness.

A CASE OF ADVANCED CARCINOMA OF THE GALLBLADDER SURVIVING FOR 4 YEARS AND 6 MONTHS, FOLLOWING EXTENDED RIGHT HEPATIC LOBECTOMY COMBINED WITH PANCREATO-DUODENECTOMY

A 51-year-old woman admitted with right hypochondralgia, palpable mass and fever was given extended right hepatic lobectomy combined with pancreato-duodenectomy for advanced carcinoma of the gallbladder which had infiltrated to the liver and duodenum. The patient died 4 years and 6 months after surgery and the autopsy revealed recurrence in the abdomen as well as metastasis to the left supraclavicular fossa and right lung. This operation method is ideal for advanced carcinoma of the gallbladder, giving apparently improved prognosis to allow long-term survival. Removal of lymphnodes of the superior mesenteric artery radicle and paraaorta is necessary for more radical treatment.

THREE CASES OF MALE BREAST CANCER

Male breast cancer is a rare clinical entity, and only 310 cases have been reported in Japan. We describe three new patients with the disease and present a statistical review of those cases reported during the 10-year-period from 1968 to 1978. Case 1, 45 years old, who exhibited a tumor (2×3cm) immediately below the right nipple, and case 2, 46 years old, with a tumor (3×3cm) near the right nipple, were treated by modified mastectomy. Case 3, 52 years old, who exhibited a tumor (5×5cm) in the left breast as well as two enlarged lymph nodes in the left axilla and one in the left supraclavicular fossa, underwent an extended mastectomy. These three patients are undergoing chemotherapy in the outpatient clinic. Prognosis of male breast cancer is considered to be poor, and early detection and surgical removal of the lesion, as in female breast cancer, are essential for achieving a satisfactory outcome. The cases presented here underline the importance of paying adequate attention to tumors involving the mammary glands in men.

Carcinoma of the prostate with soft tissue or non-regional lymphatic metastases at the time of diagnosis: a review of 47 cases.

The clinical course of 47 patients with carcinoma of the prostate who at the time of initial presentation had metastases to soft tissue or non-regional lymph nodes was retrospectively reviewed. The response rate to primary hormonal treatment (orchiectomy or oestrogens) and the duration of response were similar to those of 47 other patients presenting with skeletal metastases only. The survival of the patients in the study group was not statistically different from that of patients with skeletal metastases only. The results suggest that patients presenting initially with metastases to non-regional lymph nodes or soft tissue should be treated by the same therapeutic methods as for disseminated prostatic cancer in general (oestrogens or orchiectomy). Slight or no urinary symptoms at the time of initial presentation in spite of a locally advanced tumour was a common finding; 20% of the patients had normal serum prostatic acid phosphatase despite the presence of disseminated disease. Lymph node enlargement in the left supraclavicular fossa was the most common site of non-regional lymphatic spread. Elderly males with metastatic carcinoma in this region should be investigated for the possibility of prostatic cancer.

Esophagoplasty with an autogenous tubed gastric flap

As an esophageal substitute, a tubed gastric flap 2.5 cm in inner diameter and 38 cm in length, was constructed from the gastric wall along the greater curvature; a pedicle was attached to the gastric antrum, and its oral stump was brought up into the left supraclavicular fossa through a retrosternal tunnel to perform an esophagogastrostomy. Anastomotic breakdown occurred in only three of fifty cases in which this procedure was used.

Arborizing pulmonary embolization following lymphangiography. Report of three cases and an experimental study.

With the increasingly wide application of lymphangiography to the diagnosis of malignant disease, the hazards of the method have been a major focus of interest and concern (2, 3, 13–15, 19). The most frequent complication has been pulmonary oil embolism in the form of fine stippling observed on chest roentgenograms, with or without associated pyrexia, cough, dyspnea, chest pain, or palpitation of a minor degree. Pathologic changes in the lungs following intravenous injection of Ethiodol in animals have been described by Guiney et al. (8) and Hallgrimsson and Clouse (9). The degree to which oil may accumulate in the small arteries has received relatively little attention. The purpose of this paper is to report three instances of unique arborizing pulmonary embolization related to lymphangiography in man and to describe studies in dogs following the deliberate production of such cylindrical emboli. Clinical Material The lymphangiographic technic employed has been described elsewhere (1). Chest examinations were performed routinely prior to, immediately after, and twenty-four hours after the procedure on all patients. The chest films on 550 patients who had undergone lymphangiography were reviewed: in three, arborizing embolization was noted. In all three cases, 10 cc of Ethiodol was injected into each leg, using a gravity pressure injector. Case I (Fig. 1): J. B., a 30-year-old white female, was referred to the Stanford Medical Center for further evaluation and treatment of Hodgkin's disease. One and a half years before, she received radiation therapy for right axillary masses which had been diagnosed on biopsy as Hodgkin's paragranuloma. She had done well without systemic symptoms or recurrent masses until two months before admission, when she noted a mass in the left supraclavicular region. This continued to show slight but progressive enlargement. On physical examination, there was a 2.5 × 2 × 1.5 cm, nontender, movable mass along the lower sternocleidomastoid muscle on the left. Two small palpable lymph nodes were also noted in the left supraclavicular fossa. In the right axilla there was a small, movable, and nontender node. The spleen tip was palpable. The remainder of the physical examination and the laboratory studies were normal. The patient tolerated well both a lymphangio-graphic examination (Fig. 1, A) and inferior vena cavography.

The supraclavicular shadows in chest film interpretation.

The well known supraclavicular shadows present on most postero-anterior films of the chest are valuable aids to diagnosis, though their use has not been previously described. These shadows, as well as the sternomastoid shadows, are pointed out only as normal features, and the student is cautioned against confusing them with pathological lesions (Fig. 1). The frequency of masses in the neck resulting from lymphomata, tuberculosis, thyroid, salivary gland, laryngeal and superior sulcus tumors, and metastatic involvement from carcinoma of the breast and testes is well known. Any of these diseases may produce masses that partially or completely obliterate the supraclavicular fossae, either as a result of metastasis from a distant primary lesion or by direct extension (Fig. 2). In the past, masses in the neck have been recognized chiefly by a bulging silhouette, displaced muscle shadows, displacement of the trachea and esophagus, erosion or invasion of bone, and by the presence of calcific deposits. This report stresses the supraclavicular shadows as an additional aid in the detection of cervical masses and certain other abnormalities which involve the base of the neck. On the chest film of a white woman aged sixty, under study for possible recurrence of carcinoma of the breast, it was noted that the left supraclavicular shadow was absent, while the right was normal. Investigation revealed a 3.5-cm. firm, nodular, roughly spherical mass in the left supraclavicular fossa which proved histologically to be a metastasis. It was obvious from the film that there had been a right radical mastectomy, but no evidence of recurrent disease other than absence of the left supraclavicular shadow was present. During the few months since this sign was first observed, 11 additional cases in which abnormal supraclavicular shadows were present have been found (Table I). Case 2 is typical and will serve to illustrate the diagnostic significance of the supraclavicular shadows. On March 6, 1952, a postero-anterior film of the chest of a 35-year-old white woman revealed nothing abnormal except absence of the right supraclavicular shadow. Investigation confirmed the presence of supraclavicular masses on the right and disclosed the fact that the patient was receiving radiation therapy to the right supraclavicular region for Hodgkin's disease. A review of earlier films showed that in September 1950 there had been extensive mediastinal masses which completely disappeared after radiation therapy. The right supraclavicular shadow was found to be absent on the old films (Fig. 3), but its absence had not been detected. Chest films following completion of the recent course of irradiation showed that the supraclavicular shadow had reappeared. It was interesting to note that the shadow was now thicker than the normal one on the opposite side (Fig. 4).

Brachial plexus irritation due to hypertrophied omohyoid muscle; a case report.

It is recognized that the results of surgery for the scalenus anticus syndrome have, in many cases, been disappointing. It is the purpose of this report to suggest that the possible cause for failure, in some of the patients, may be due to unrecognized pressure on the brachial plexus from either a taut or a hypertrophied lateral belly of the omohyoid muscle. It is not the intention of the author to discuss the scalenus anticus syndrome itself, since the subject has been dealt with exhaustively in the literature. A 30-year-old Caucasian housewife was seen Feb. 8, 1951, complaining of a mass in the left supraclavicular fossa of 10 months' duration. Four months previous to her first visit, while reaching into a deep box with the left arm and turning her head to the right to speak to an acquaintance, she experienced a sudden onset of pain involving the left side