Case Presentation and Discussion

Anterior Chest Wall Mass

Pip Acepcion, MD
Year I Surgery Resident
GSI, Department of Surgery, Philippine General Hospital
1999

Notes from the Facilitator

Note 1: The surgical resident was asked to read the self-instructional program entitled "Management of a Surgical Patient" written by the undersigned and used it as a guide to present and discuss the case. This is his output. My comments are seen in the "text areas" within and at the end of the manuscript.

Note 2: I welcome reactions not only from Dr. Pip Acepcion but also from readers. Forms are provided at the end of the manuscript for this purpose or email can be used.

Note 3: The same case was presented and discussed by other surgical residents, Dr. Caesar Casanova and Dr. George Repique. You may want to read this too and compare.

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
Facilitator

Case Presentation and Discussion

This is the case of a 50 year old male, hypertensive, from Lumban, Laguna who presents with a 2 year history of a slow-growing right anterior chest wall mass with no other associated signs and symptoms.

EXPECTATIONS

1. I am to manage this patient's health problem;
2. In so doing, I am to endeavor in a problem-solving/decision-making activity;
3. Essentially, my goal is to provide solution to my patient's health problem which will both benefit my patient and myself;
4. I will be confronted with the following tasks:
   • ENTRY: establishing rapport and trust of patient and patient's relatives.
   • To formulate a sound clinical diagnosis and to be able to give advise to patient on the findings and diagnosis.
   • To be able to decide on a cost-effective paraclinical procedure.
   • To decide on the most cost-effective treatment procedure.
5. The outcome of the management should be rational, effective, efficient and humane.

Rapport

Especially for patients that you will only meet for the first time, and in a charity ward setting, gaining entry is the most important step in earning patient and his relatives' trust and confidence.

The following are ways of establishing rapport:

• being courteous
• extending due respect to patients and their relatives
• being a good listener
• encouraging a lively, yet professional interactions
• being honest with regards to diagnosis, procedures, and resources
• showing enthusiasm

Clinical Diagnosis

The patient presents with the chief complaint of right anterior chest wall mass, which on palpation and inspection reveals a 12 x 12 cm soft, non-tender mass on the right anterior chest area. My initial impression, therefore, is right anterior chest wall mass.

Place an illustration of your physical examination findings!

By location, the mass could originate from the following:

• skin
• subcutaneous tissue
• muscle
• rib
• lymph node

The skin will be least in our considerations because of the fact that there are no skin changes associated with the mass. It could also not come from the bony structures of the chest wall since the mass is fairly soft and there are no evidences of hard lesions within the mass. We are now left with 3 possible sources of the mass, namely; subcutaneous tissue, muscle (collectively, soft tissue), and lymph node. With regards to the latter, if indeed the mass arises from it, it is most likely metastatic. To investigate, we should palpate and inspect the probable pathway of the lymphatics which may lead us to the primary lesion. In this case, there were no lesions found in both upper extremities, on the chest (aside from the mass in consideration), and on the head and neck areas. We are now left with the subcutaneous tissue and muscle as probable sources of the mass. Collectively, we refer to them as soft tissues.

At this point, our impression is, right anterior chest wall mass, most likely arising from soft tissue structures (subcutaneous tissue and muscle).

The next step is to differentiate whether the mass is inflammatory, malignant or non-malignant. In this patient the mass shows no signs of infection. It is non-tender, non-erythematous, with no change in temperature, and there are no associated signs and symptoms pointing to an inflammatory process. This mass is, therefore, not inflammatory.

In terms of malignancy, I am bent more on considering that this mass is non-malignant based on the fact that this mass is present since 2 years prior to present consult, slow-growing in character, with no constitutional signs and symptoms. On physical examination, the mass is soft, movable with no note of metastasis elsewhere. These, of course, do not negate the possibility that this mass is malignant.The slow growing statement of yours is open to question. A mass 12 cm in size in 2 years - not every body will agree this is slow-growing. What do you mean by constitutional signs and symptoms? Signs and symptoms of cancer? Amplify!

My clinical diagnosis at this point is:

Soft tissue tumor, right anterior chest wall, probably benign

My secondary consideration:

Malignant soft tissue tumor, right anterior chest wallWhat is your basis for the secondary diagnosis? Why not another benign tumor as the secondary diagnosis?

Paraclinical Diagnostic Procedures

I feel that there will be no need for a paraclinical diagnostic procedure since the treatment of choice for this case, whether benign or malignant, is complete extirpation of the mass. There is no point, therefore of differentiating the two prior to the contemplated procedure.

What does complete extirpation of a benign mass entail? What does complete extirpation of a malignant mass entail? Is the extent of extirpation the same? You missed on the use of degree of certainty factor in deciding whether you need a paraclinical diagnostic procedure or not!

Treatment

The goal of treatment is to completely extirpirate all gross tumors and to ensure that there will be no local recurrrence and/or complications.

The most cost-effective mode of treatment is surgery (wide excision).

Pre-op Preparations

Pre-operatively, the patient should be prepared physically, mentally, and emotionally. Fears and anxieties should be allayed with proper explanation of the procedure and the possible outcome. Relative's support should be tapped.

An informed consent should be asked from the patient both for his welfare and the doctor's.

Physically, patient should be assesed if indeed he can handle the rigors of surgery. We should optimize his physical health with proper assessment and treatment of co-existing medical problems. My patient is a hypertensive and would need to seek consult from a medical specialist.

Needs for surgery should also be prepared and readied beforehand.

Intraoperative Management

The incision should be long enough for intraoperative assessment and complete excision of the soft tissue mass without complications, cosmetically acceptible. Exposure of the whole mass, intraoperatively is useful for complete extirpiration. The margins of excision should be wide enough to eliminate possibility of local extension. Careful hemostasis on removal of the mass should be done to avoid untoward bleeding. A drain may be used to prevent unwanted accumulation of fluid in the wound space. Closure of wound should be undertaken meticulously with the proper choice of sutures.

Post-op care

• Supply basic needs of patient:
  • comfort
  • pain control
  • fluids and electrolytes
  • nutrition (diet as tolerated once fully awake)
• wound care
• home instructions

Follow-up Plan

Useful to evaluate the result of treatment as well as to monitor the progress of patient. Frequency depends on the urgency of the matter as well as the decision of the patient.

Look up for reliable cues for soft tissue sarcoma.

Suggestions to Dr. Pip Acepcion on improvement of case presentation and discussion:

1. Refer to the format of a general case presentation and discussion.

2. Refer to the format used in "Management of Surgical Patient."

3. Use the Evaluation Form below as a guide.

4. Read the case presentation and discussion of Dr. Caesar Casanova and Dr. George Repique.

Reactions from Dr. Pip Acepcion

(You can use the text area below and then press the "submit" button or
you can email me your reactions.)

rjoson@pacific.net.ph

Questions and Comments from Readers

(You can use the text area below and then press the "submit" button or
you can email me your questions and comments.)

rjoson@pacific.net.ph

Dr. George Repique's Case Presentation and Discussion
Dr. Caesar Casanova's Case Presentation and Discussion
GSI Case Presentation and Discussion
GSI Frontpage