Supraclavicular Mass Research Articles

Case report of a primary ectopic extradural and extraspinal meningioma of the brachial plexus

Primary ectopic extradural and extraspinal meningiomas are rare. We present a unique case of this type of meningioma in the brachial plexus.A 25-year-old man consulted us because of neuropathic supraclavicular pain and the appearance of a supraclavicular mass whose volume had increased. Clinical examination found paresis of the deltoid, biceps brachii and brachialis muscles rated as M4 (MRC) and a strong Tinel sign at the supraclavicular fossa, over the palpable mass. There was no sign pointing towards central nervous system involvement or altered general condition. MRI revealed a mass measuring 53 × 24 mm invading the C5-C6 plexus roots and the primary upper trunk, but not the bone or spinal area. This lesion was hyperintense on DWI/ADC, hyperintense on T2 with hypointense spots, and hypointense on T1 with intense heterogeneous gadolinium enhancement.Excisional biopsy was done 6 months after symptoms started. The tumor had developed at the C5 root, which was fibrous and at the C6 root, which was grossly normal.Anatomical pathology confirmed the WHO grade 1 meningioma, meningothelial and psammomatous histological subtypes.At 6 months, a follow-up MRI found no postoperative tumor remnants or recurrence. During the postoperative course, persistent paralysis of the deltoid muscle at 5 months justified a nerve transfer.This is a rare case of ectopic extraspinal and extradural meningioma of the brachial plexus. The diagnosis of an ectopic meningioma must be considered when a patient presents with a brachial plexus tumor causing neurological deficits. The extradural nature is not sufficient to rule out this diagnosis.

Neck mass and bilateral pleural effusions in a 53-year-old female.

Chylothorax indicates the accumulation of chyle in the pleural cavity. It is a rare cause of pleural effusion, especially bilaterally. In clinical practice, the presence of milky fluid in the pleural cavity raises the suspicion of chylothorax. The most common cause is trauma, iatrogenic or non, owing to thoracic duct injury, which transports chyle from the lymphatic system into the bloodstream. The case we describe is of a 53-year-old female who was referred to our hospital with bilateral pleural effusions and a left supraclavicular mass. From the diagnostic studies, the nontraumatic causes of chylothorax were excluded. The potential diagnosis was traumatic chylothorax, a diagnosis of exclusion, as it appeared after muscle stretch and receded with a fat-free diet and repose without any relapse.

Intracapsular Enucleation of Brachial Plexus Schwannoma With Intraoperative Neuromonitoring: A Case Series Study and a Review of Literature.

Brachial plexus schwannoma (BPS) is a rare clinical entity that poses a significant challenge for head and neck surgeons due to its neuroanatomical complexity and potential severe complications, such as major motor or sensory neurological deficits or pain of the corresponding upper extremity. This article summarizes our experience in its diagnosis and intracapsular enucleation with intraoperative neuromonitoring (INM). A retrospective review of BPS cases treated at our tertiary medical institution was conducted between April 2020 and May 2023. The clinical and demographic data were retrieved from case notes. Totally, 3 cases were included. All 3 patients were male, aged 43 to 54 years (median age = 52). The presenting symptom was a palpable supraclavicular mass in all these cases (2 on the left side and 1 on the right side). Neuromonitoring was performed with a 4-channel nerve integrity monitor, with the electrodes placed in the upper arm and forearm muscles, as demonstrated in the literature. After exposing the mass and identifying its origin from the brachial plexus, a unipolar stimulating probe was used to stimulate the tumor surface or the nerves with a 1.0-mA current, and a longitudinal incision into the tumor capsule was made along a carefully mapped line with no INM response. Then the mass was carefully exposed and meticulously dissected from its capsule to achieve an intact enucleation. Immediate postoperative neurological deficit was documented in Case 1 as a mild grasping weakness. The recovery of the other 2 patients was uneventful. The follow-up duration was 7 to 38 months (median = 8 months). The minor motor deficit of Case 1 recovered completely 1 month after surgery. No recurrence of BPS was observed. Intracapsular enucleation with INM could result in complete removal of BPS and minimal postoperative neurological deficit, whose recovery was quick and satisfactory.

EWSR1 rearranged primary renal myoepithelial carcinoma: a diagnostic conundrum.

Primary renal myoepithelial carcinoma is an exceedingly rare neoplasm with an aggressive phenotype and Ewing sarcoma breakpoint region 1 (EWSR1) rearrangement in a small fraction of cases. In addition to its rarity, the diagnosis can be challenging for the pathologist due to morphologic heterogeneity, particularly on the biopsy specimen. At times, immunohistochemistry may be indecisive; therefore, molecular studies should be undertaken for clinching the diagnosis. We aim to illustrate a case of primary myoepithelial carcinoma of the kidney with EWSR1-rearrangement in a 67-year-old male patient who presented with right supraclavicular mass, which was clinically diagnosed as carcinoma of an unknown primary. An elaborate immunohistochemical work-up aided by fluorescent in-situ hybridization allowed us to reach a conclusive diagnosis. This unusual case report advocates that one should be aware of the histological mimickers and begin with broad differential diagnoses alongside sporadic ones and then narrow them down with appropriate ancillary studies.

Case Report with a Review of Literature: Pancoast Syndrome—A Rare Presentation of Metastatic Hepatocellular Carcinoma

AbstractSuperior sulcus tumors, also known as Pancoast tumors, present in a distinctive way with Horner's syndrome (ptosis, miosis, and anhidrosis), hand weakness brought on by the atrophy of the intrinsic hand muscles, and excruciating pain along the medial aspect of the arm. (1) Primary lung cancers constitute a majority of Pancoast tumors, but Pancoast syndrome can be multifactorial. (2) Here, we present a case of 62-year-old male who presented with right shoulder pain and weakness for 2 months. Clinically, he had a supraclavicular mass with atrophy of the intrinsic muscles of the hand and sensory-motor weakness. Computed tomography showed a mass lesion in the supraclavicular fossa with the erosion of the T1 vertebra and first rib, mimicking carcinoma right upper lobe. However, the biopsy from the mass was suggestive of metastasis from hepatocellular carcinoma (HCC). Our case report identifies HCC as a rare differential for Pancoast syndrome and highlights the unique metastatic presentation.

Pseudoarthrosis of unilateral cervical rib and 1st rib exostosis-presenting with supraclavicular mass and thoracic outlet syndrome

Cervical rib is defined as the presence of supernumerary rib at the 7th cervical vertebrae possibly associated with mutations in Hox genes. Cervical rib may have a free end or may be fused with the first rib by bone bridge or fibrous band. However, the incidence of pseudoarthrosis of cervical rib with exostosis from the first rib is reported rarely in literature. This report documents a unilateral pseudoarthrosis of cervical rib with 1st rib exostosis presenting as a supra clavicular mass with thoracic outlet syndrome.

Left supraclavicular Lymphadenopathy as initial presentation of prostate Adenocarcinoma: An unusual presentation of a common cancer

Left supraclavicular lymphadenopathy is an ominous finding of physical examination. An underlying malignancy is found in about 50% of cases. This case report describes a male patient admitted for acute heart failure and respiratory infection. During physical examination a large left supraclavicular mass was identified. There were no symptoms or other findings suggesting malignancy. A full body Computed Tomography (CT) scan imaging revealed generalized lymphadenopathy. The histopathological examination of a cervical lymphadenopathy suggested metastasis of a poorly differentiated carcinoma. Prostate specific antigen level was very high (325 µg/L). The digital rectal examination and prostate biopsy confirmed the diagnosis of prostate adenocarcinoma. Even though this is an uncommon presentation of a very frequent disease, finding a supraclavicular lymphadenopathy in male patients should raise the suspicion of metastatic prostate cancer.

Woman with Supraclavicular Mass.

Woman with Supraclavicular Mass.

A Rare Case of Metastatic Extragonadal Yolk Sac Tumor – A Challenging Diagnosis on Cytomorphology

Abstract Introduction/Objective Yolk sac tumors are characterized by variable histologic patterns and broad cytologic spectrum; thereby making the distinction from a poorly differentiated adenocarcinoma in a metastatic site extremely challenging. We present cytology and histology of a metastatic extragonadal germ cell tumor with predominant solid yolk sac component. Methods/Case Report 36-year-old male presented with bilateral supraclavicular masses (right: 6 x 7 cm, left: 3 x 4 cm). CT chest and abdomen revealed large mediastinal and hilar nodal mass (11.6 cm), right hilar mass (8.5 cm), bilateral heterogeneous adrenal masses (right: 11.4 cm, left: 3.1 cm), and an enhancing retroperitoneal implant. Differential diagnoses of lymphoma, adrenocortical carcinoma, small cell lung carcinoma, and metastatic germ cell tumor were considered. Testicular ultrasound revealed no masses. Fine needle aspiration of supraclavicular lymph nodes showed highly cellular smears comprised of tumor cells, dispersed singly and in clusters, with irregular nuclear contours, increased nuclear to cytoplasmic ratio, coarse chromatin, occasional prominent nucleoli, and vacuolated cytoplasm. Tumor cells were positive for KRT7 and TTF-1, and negative for p40 and PAX8. A diagnosis of metastatic poorly differentiated carcinoma was rendered. Subsequent excisional biopsy of the lymph node showed a metastatic tumor with tumor cells similar to those seen in cytology, appearing in solid sheets with focal papillary architecture, replacing the entire lymph node. Additional immunohistochemistry showed expression of SALL4, Glypican 3, with lack of expression for OCT3/4, AFP, hCG, and CD30, supporting the diagnosis of metastatic yolk sac tumor, solid pattern. Results (if a Case Study enter NA) NA. Conclusion Aggressive clinical presentation, broad clinical differential diagnoses, rarity of a primary mediastinal yolk sac tumor, non-diagnostic cytomorphology along with expression of divergent differentiation markers (TTF-1 in our case) makes a definitive diagnosis of metastatic extragonadal yolk sac tumor extremely challenging. High index of clinical suspicion is required for a definitive diagnosis on cytomorphology.

Pseudogout Causing Thoracic Outlet Syndrome

Abstract Introduction/Objective Calcium pyrophosphate dihydrate (CPPD) crystal deposition or pseudogout is a common entity encountered in routine practice. However, when a common entity presents in uncommon locations with unusual clinical manifestations, it creates a diagnostic conundrum. Pseudogout commonly occurs in the joint extremities including knee, wrist, shoulder, hip, and ankle joints. The sternoclavicular joint is a rare site for pseudogout with very low incidence. To the best of our knowledge, there are only two other cases of pseudogout mimicking a tumor causing vascular obstruction in the literature. Methods/Case Report A 63 year old male presented with an enlarging supraclavicular mass. A computed tomography angiography scan of the chest revealed an irregular soft tissue mass located behind the medial clavicle measuring up to 4 cm and was noted to compress and partially occlude the right subclavian vein. Partial occlusion of right axillary vein, right internal jugular vein, and right brachiocephalic vein were also noted on imaging. The venous compression led to outflow obstruction and resultant recurrent deep vein thrombosis of the right upper extremity. Due to compression by the mass, he required stenting of the right subclavian vein which unfortunately reoccluded. Subsequently, the patient underwent excision of the mass and partial resection of the first rib with decompression of the thoracic outlet. The excisional biopsy revealed dense rhomboid-shaped CPPD crystal depositions in irregular nodules within a background of fibrinoid material and fragments of unremarkable cartilaginous tissue. The patients compressive symptoms were relieved following the excision. While clinically and radiologically the mass was concerning for a malignant tumor, histological examination provided a definitive diagnosis of a benign process. Results (if a Case Study enter NA) NA. Conclusion Pseudogout is a rare mimicker of bone and soft tissue tumors and differentiation from an enchondroma, or grade 1 chondrosarcoma becomes a challenge especially on small tissue biopsies and is a possible diagnostic pitfall.

PSAT289 Extranodal Marginal Zone B-Cell Lymphoma of the Mucosa-Associated Lymphoid Tissue (MALT) Type of the Thyroid: A Rare Tumor That Requires a Second Look

Abstract Background Extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type of the thyroid, or MALT lymphoma of the thyroid, is a rare, indolent tumor that accounts for only 1-2% of extranodal lymphomas. It is often associated with lymphocytic thyroiditis - a benign condition that might not be given additional investigation. Clinical case A 79-year-old male consulted due to a 3-year history of a gradually enlarging, painless anterior neck mass accompanied by hoarseness. He denied fever, weight loss, dysphagia, dyspnea, palpitations, heat or cold intolerance, or changes in bowel movement. On physical exam, a 4×3×1 cm firm, fixed, non-tender right anterior neck mass and a 2×2 cm right supraclavicular mass were palpated. Thyroid function tests showed: TSH 3.301 uIU/mL (0.55 - 4.78 uIU/ml), FT3 2.560 pg/mL (2.30 - 4.20 pg/mL) and FT4 0.720 ng/dL (0.89 - 1.76 ng/dL). Neck ultrasound revealed multiple cervical lymph nodes measuring 1-2 cm in the right anterior, posterior, submandibular, and left submandibular areas. A lobulated heterogeneous mass measuring 9.7×2.9×4.3 cm occupied almost the entire right thyroid lobe, with intralesional and peripheral vascularity. The left thyroid lobe had an irregular, solid, isoechoic nodule measuring 0.9×0.5×0.9 cm. Fine needle aspiration biopsy of the right thyroid mass showed lymphocytic thyroiditis (Bethesda category II). The patient underwent total thyroidectomy with frozen section and selective neck dissection on the right (levels II, III, IV, and V). Final histopathology and immunohistochemical stains revealed extranodal marginal zone lymphoma of the thyroid gland, with high grade transformation to diffuse large B-cell lymphoma in 10% of the tumor. Level II, III and V lymph nodes were positive for marginal zone lymphoma. Histopathology also showed an adenomatous goiter with lymphocytic thyroiditis. The patient was started on levothyroxine 75 mcg once daily. He completed 1 cycle of chemotherapy (R-CHOP). Two weeks after chemotherapy, he developed febrile neutropenia and expired due to sepsis. Conclusion In thyroid nodules and masses where lymphocytic thyroiditis is identified on fine needle aspiration biopsy, particularly in large masses accompanied by cervical lymphadenopathy, the possibility of an existing MALT lymphoma of the thyroid should be considered, and further investigation may be warranted. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

SEVERE PRURITUS AS A PRESENTING SYMPTOM OF HODGKIN'S LYMPHOMA

<h3>Introduction</h3> Pruritus has a broad differential diagnosis. Rarely, this symptom may be the sole manifestation of an underlying malignancy. A patient with 5 years of severe upper body pruritus with no other systemic symptoms was subsequently diagnosed with Hodgkin's lymphoma. <h3>Case Description</h3> A 43-year-old male presented to the allergy-immunology clinic for evaluation of severe pruritus of 3 years' duration; he reported nocturnal worsening awakening him from sleep. The pruritus was refractory to antihistamines but was partially responsive to ice packs. There were no associated constitutional or respiratory symptoms, or lymphadenopathy. CBC with differential and CMP were normal. Omalizumab therapy was administered for 3 months; however, the severe pruritus persisted. Neuropathy work-up by neurology was negative. Dermatology evaluation yielded a diagnosis of folliculitis. Work-up for auto-immune disease by rheumatology was negative. After a total of 5 years of pruritus without identifiable cause, he presented for evaluation of a new-onset supraclavicular mass. Chest CT revealed a large anterior mediastinal mass and a massive conglomerate of lymph nodes. Subsequent biopsy revealed classic Hodgkin's lymphoma. <h3>Discussion</h3> This case underscores that persistent pruritus may be the presenting symptom of malignancy. Pruritus associated with malignancy is classically refractory to antihistamines and may not be accompanied by classic systemic symptoms. While rare, it is important to keep this atypical presentation of malignancy in the differential.

S3597 Extensive Gastric Mucormycosis in a Patient With Newly Diagnosed Diffuse Large B-Cell Lymphoma of the Stomach

Introduction: Non-Hodgkin’s lymphoma (NHL) affects the gastrointestinal tract in 10 to 15 percent of the cases. Mucormycosis in the gastrointestinal tract is rare and may cause severe infection in immunocompromised patients with hematological malignancy. We present a case of newly diagnosed diffuse large B-cell lymphoma (DLBCL) with malignant masses in the stomach and extensive ulcerations with mucormycosis. Case Description/Methods: A 62 year-old man with a history of hypertension presented with left abdominal pain and weight loss, associated with decreased appetite. Abdominal exam unremarkable, but there was a nontender left supraclavicular mass. Initial labs revealed mild microcytic anemia with elevated ferritin and C-reactive protein. Computed tomography showed multiple lymphadenopathy above and below the diaphragm with gastric wall thickening at the fundus. Upper endoscopy revealed multiple duodenal nodules, mucosal inflammation at the antrum and multiple masses with non-bleeding deep ulcers at the fundus (Figure). Biopsy revealed CD20 positive large atypical cells with flow cytometry confirming the diagnosis of DLBCL with germinal center type. Fluorescent in situ histochemistry (FISH) was negative for double-hit lymphoma. Biopsy of the ulcers also showed Mucorales identified by GMS and PAS-D stains. Patient was started on posaconazole prior to initiation of chemotherapy with R-CHOP. Discussion: The stomach is the most common gastrointestinal location of extranodal NHL. Diagnosis is confirmed by immunohistochemistry or flow cytometry. Germinal center B cell (GCB) is associated with a favorable prognosis. FISH is used to rule out double or triple-hit high-grade lymphoma with MYC and BCL2 and/or BCL6 rearrangements. Standard treatment consists of six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) with 60 percent cure rate in patients with DLBCL. Mucormycosis is caused by mold found in decaying vegetation and soil. Immunocompromised hosts are at risk of potentially fatal angioinvasive infection with local ischemia, necrosis and deep ulcerations. Gastrointestinal mucormycosis occurs in only 7% of reported cases, most commonly affecting the stomach. Empiric treatment with polyene antifungal is necessary. Surgical resection may be needed if there is massive bleeding or impending perforation. Delaying treatment increases mortality by two-fold. Early diagnosis and treatment of mucormycosis is imperative for successful outcome.Figure 1.: Endoscopic findings in the stomach; a. 5-8 mm nodular masses at the duodenal bulb; b. Scattered mucosal inflammation at the gastric antrum; c, d & e. Malignant mass with ulceration at the gastric fundus.

Desmoplastic Fibroblastoma of the Supraclavicular Region: A Rare Soft-Tissue Tumor With a Review from the Last Decade.

Desmoplastic fibroblastoma (DF) is primarily a sporadic, rare, benign, soft-tissue tumor with an excellent prognosis and no reported recurrence to date. DF presents as a painless, slow-growing mass with symptoms due to its mass effect. We report a case of a middle-aged man presenting with a right supraclavicular mass and numbness of the right arm, eventually diagnosed as DF. After confirming the diagnosis with imaging and biopsy studies, the tumor was successfully excised using a transcervical approach with no complication or recurrence detected during the 2-year follow-up after surgery. A review of the relevant literature is presented regarding the presentation, diagnosis, and outcomes of published case reports of DF coinciding with those of our discussed case. This case report adds to the pool of uncommon DF cases mainly for its unique symptoms and location. It also highlights the necessity of health education related to painless masses that might be attributed as trivial in the community.

A supraclavicular cystic lymphangioma in adult: a rare entity

Cystic lymphangioma is a benign congenital disease that is more seen in head and neck regions. We report a case of a 54-year-old man with a growing supraclavicular mass. The ultrasonography and magnetic resonance imaging suggested a cystic lymphangioma. The mass was surgically totally removed without any recurrence. Histology examination confirmed the diagnosis. Cystic lymphangioma in adults is a rare entity and the literature on the subject is poor with no global recommendations.

The Importance of Metastatic Papillary Serous Carcinoma in Cases of High-grade Encapsulated Papillary Carcinoma of the Breast: An Extremely Rare Case and a Possible Pitfall

Background: Encapsulated papillary carcinoma (EPC) of the breast has a favorable prognosis. High-grade EPCs, triple-negative or HER-2-positive, are dealt with as invasive carcinomas. Breast metastasis associated with serous carcinoma is a late-stage event. The discrimination between the two diagnoses can be very challenging.Case Presentation: A 79-year-old woman with a history of well controlled high-grade serous papillary carcinoma of the peritoneum went through a total left mastectomy and sentinel lymph node biopsy (SLNB) because of an invasive carcinoma in her left breast. In the lab, a peripheral nodular mass of 4cm was found. Microscopically, large intracystic papillary stalks, with high nuclear grade, surrounded by collagenous tissue were identified compatible with invasive encapsulated papillary carcinoma with positive estrogen receptor. A few months later, the patient was diagnosed with a supraclavicular cervical mass, which on FNB was indicative of metastatic serous papillary carcinoma. Immunohistochemical stains were similar in breast and previously treated peritoneal tumor showed ER+, PAX8+, p53+ (wild type) and high Ki-67 (80%). WT1 was positive only in peritoneal serous carcinoma. GATA-3 was weakly, scarcely expressed in both specimens. The findings pointed to metastatic SPC in the breast, mimicking primary carcinoma of the EPC type. Conclusion: Pathology of breast metastases and distincion from primary breast cancers is done by a combination of morphological and IHC features. In our case, the lack of clinical history, the type of surgical approach (mastectomy and SLNB), the solitary lesion, the EPC pattern of growth and the diffuse ER+ staining, were indicative of primary breast lesion. Various morphologic growth patterns of metastatic PSC have been described, among which EPC-like needs to be considered.

Sarcomatoid Chromophobe Renal Cell Carcinoma

Dear Editor, We read with great interest and attention the recent paper by De La Parra and co-authors on the sarcomatoid transformation of chromophobe renal cell carcinoma.[1] In the review of the literature, these authors incorporate 10 cases of this uncommon condition including two own cases (their Table 1). However, the article of Akhtar et al.[2] and the work of our group[3] on this kind of tumor are missing. The first case of sarcomatoid chromophobe renal cell carcinoma was published by Akhtar et al. in 1996.[2] The patient, a 64-year-old woman, was admitted because of a six-month history of right upper quadrant pain and a mass in the right flank. Ultrasound and CT scan of the abdomen showed a large mass invading the anterior portion of the kidney. A chest radiograph revealed a questionable metastatic lesion in the right lung. A radical nephrectomy was performed. The nephrectomy specimen weighed 1050 g. The kidney was extensively replaced by a multinodular, firm, well delimited, 7x5x4 cm mass. Pathologic diagnosis was sarcomatoid chromophobe renal cell carcinoma showing presence of equal proportions of carcinoma and sarcomatoid component. The carcinoma component was positive for colloidal iron acid stain, cytokeratins (CKs) 8,18,19, and epithelial membrane antigen (EMA). One year later, she was readmitted. Ultrasound examination of the abdomen revealed enlargement of para-aortic and mesenteric lymph nodes and massive recurrence of the tumor in the right renal bed. Besides, a metastatic nodule in the right lung and a supraclavicular mass were also present. She was given palliative radiotherapy to the renal bed and then discharged. She did not return for her follow-up visit and was considered dead. In 1997, we described one case of this aforementioned neoplasm.[3] A 61-year-old man presented with a sixmonth history of hematuria. A CT scan revealed an 11 cm hypodense mass with a central scar in the lower pole of the right kidney, suggesting the diagnosis of renal oncocytoma. The patient underwent a right radical nephrectomy. The right nephrectomy specimen weighed 667 g and measured 17x11x7.5 cm. The kidney presented an 11.2 cm light brown mass in the lower pole with hemorrhagic and necrotic foci that infiltrated the renal capsule and the perinephric adipose tissue (pT3aN0M0, stage III UICC). The microscopic study revealed a neoplasm composed of sheets of voluminous polygonal epithelial cells, with a narrow zone of condensation along the cell boundaries and translucent finely reticulated cytoplasm. The nuclei were central and vesicular with some areas where small nucleoli could be identified. 40% of the tumor displayed spindle-shaped and pleomorphic cells with large nuclei and prominent nucleoli and a significant number of mitotic figures (5/10 HPF; where 1HPF = 0.1924 mm2 ). Epithelial cells showed an intense diffuse reaction of the cytoplasm with Hale´s

Abstracts Presented at the 2nd Annual Advancing Healthcare Innovation Summit: Nov 11, 2022, Cincinnati, OH

Abstracts Presented at the 2nd Annual Advancing Healthcare Innovation Summit: Nov 11, 2022, Cincinnati, OH

Congenital cervical rib causing thoracic outlet syndrome

Thoracic Outlet Syndrome (TOS) is a common condition caused by compression of neurovascular vessels traveling through the thoracic outlet. There are three categories of TOS, arterial (aTOS), neurogenic (nTOS), and venous (vTOS). These commonly present with pain in the neck, upper extremity weakness, paresthesia, swelling, and discoloration. TOS can be caused by a cervical rib, which is a rare and usually benign anomaly. This typically results in aTOS. This case, however, presents a 13-year-old male patient with nTOS caused by a cervical rib. He presented with weakness and pain of his right arm and a prior history of a partial neck mass resection. A physical exam revealed a firm supraclavicular mass and X-ray images confirmed the diagnosis of nTOS. Surgical resection of the anomalous rib was performed via a supraclavicular approach. Due to the difficulty of this operation, a multidisciplinary surgery team was formed, ensuring a positive outcome for the patient. To our knowledge only two case reports of nTOS caused by a cervical rib compression of the brachial plexus exist. One was iatrogenic and the other treated non-surgically. Due to this lack of knowledge as well as the debate on surgical versus non-surgical treatment of TOS, this case report seeks to bolster the current literature with a positive outcome to correction of a rare presentation.

Left cervical swelling due to lymphatic intraluminal obstruction.

A 42-year-old woman had presented to the outpatient clinic because of a swelling of the left cervical region. Her medical history was remarkable for multiyear episodes of recurrent cervical swelling with abdominal pain that always regressed spontaneously. The physical examination showed a soft nontender mass in the left supraclavicular fossa without pain or skin redness (A). Magnetic resonance lymphography (B) without contrast injection showed a marked dilation of the thoracic duct (arrowhead). We also visualized a dilation of the cervical lymphatic duct network (long arrow). The terminal part of the thoracic duct showed a segmental dilation ≤13 mm with visualization of lymphatic intraluminal obstruction (LIO; short arrows). Ultrasound examination (C) focused on this area confirmed the LIO of the terminal portion of the thoracic duct. No other lymphatic or vascular malformations were demonstrated by thoracoabdominal computed tomography or magnetic resonance imaging. One week later, the patient had recovered uneventfully with complete resorption of the cervical swelling. Because the cervical swelling had spontaneously resolved, surgery was not considered.1Veziant J. Sakka L. Galvaing G. Tardy M.M. Cassagnes L. Filaire M. Lymphovenous anastomosis for recurrent swelling syndrome and chylous effusion due to cervical thoracic duct cyst.J Vasc Surg. 2015; 62: 1068-1070Google Scholar A supraclavicular mass can arise from infectious disease, a branchial clef cyst, or a benign or malignant tumor. LIO of the thoracic duct is a rare condition that can cause recurrent swelling of the cervical region.2Kunze G. Staritz M. Lymph vessel thrombus detection in cervical lymphedema: a case series.J Ultrasound Med. 2017; 36: 1955-1960Google Scholar Magnetic resonance lymphography without contrast media injection allows for easy visualization of the lymphatic duct network and can directly demonstrate the LIO without the need to inject contrast media.3Cholet C. Delalandre C. Monnier-Cholley L. Le Pimpec-Barthes F. El Mouhadi S. Arrivé L. Nontraumatic chylothorax: nonenhanced MR lymphography.Radiographics. 2020; 40: 1554-1573Google Scholar,4Arrivé L. Derhy S. El Mouhadi S. Monnier-Cholley L. Menu Y. Becker C. Noncontrast magnetic resonance lymphography.J Reconstr Microsurg. 2016; 32: 80-86Google Scholar The patient gave her written informed consent for the report of her case details and imaging studies.