Case Presentation and Discussion

Anterior Chest Wall Mass

George R. Repique, MD
Year V 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.

Note 2: You are welcome to make comment and ask questions.

Note 3: You are invited to look at the manuscript containing my comments.

Note 4. You are invited to compare the case presentation and discussion of the same patient by Dr. Caesar Casanova and
Dr. Pip Acepcion, other surgical residents.

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

CASE PRESENTATION AND DISCUSSION

CLINICAL DIAGNOSIS

In this particular patient, the expressed chief complaint is an anterior chest wall mass. To verify, I looked and palpated the area pointed to by the patient. I saw and felt a 12 x 12 cm mass in the superior portion of the anterior chest wall. With these findings, I conclude that there is really an anterior chest wall mass on the right side. Initial impression of the patient's health problem, therefore is a RIGHT ANTERIOR CHEST WALL MASS.

The next thing to do is to determine the organ or tissue of origin of the anterior chest wall mass. By it's location, the mass can come from any of the following organs or tissues:

• Skin
• Soft tissue
• Breast tissue
• Bone

The mass is originating from the skin if I see a superficial lesion on the skin surface. In this patient, there is no break or lesion in the skin. The mass is underneath the skin. I conclude, therefore, that the mass is most likely NOT a skin tumor. I'll say the mass is originating from the bone if I feel the mass is a bony tumor. In this patient, the mass does not feel bony. I conclude, therefore, that this mass is most likely NOT a mass arising from the anterior ribs.

The anterior chest wall mass is beneath the skin and not a bony tumor. The considerations in the tissue or organ of origin are now trimmed down to the following:

• Breast tissue
• Soft tissue

At this patient, after finishing my inspection and palpation of the right anterior chest wall mass, I have gotten the following data:

Right anterior chest wall mass, beneath the skin, not a bony tumor, 12 x 12 cm in size, not hard, movable, non-tender, border well-defined

I feel I should investigate first the breast tissue possibility because it is more accessible. Since the mass is deeper than the muscle and it is far far away from the nipple-areolar complex where the breast tissue in males are concentrated on, breast tissue is unlikely.

At this point, my impression is an anterior chest wall mass, most likely arising from the soft tissues. I need to be more specific to include the possible disorder, whether inflammatory, malignant, or non-malignant.

Thus, the next thing I will do is look for signs of inflammation like pus, erythema, tenderness and warmth. If there are signs of inflammation, then my diagnosis will be intramuscular abscess, depending on whether there is fluctuancy or not. In this patient, there are no signs of inflammation. I conclude that most likely, the mass is NOT inflammatory.

The next thing I will do is look for signs of malignancy, which include a hard, non-osseous solid tumor, fixation/invasion of the skin, presence of axillary lymph nodes and a distant mass suspicious for metastasis. If any of these signs is present, then my diagnosis will be a soft tissue sarcoma. In this patient there are no signs of malignancy. I conclude, therefore that most likely, the mass is NOT malignant.

With no signs of inflammation, and malignancy, I am left with a non-malignant tumor consideration. Before I settle for this consideration, I will look for signs and other clues of benignity. A reliable clue will be a cystic nature of the mass. As for other clues of benignity, the duration of the mass may help. If the mass has been present for a long duration of time without causing symptoms and there are no signs of malignancy, most likely the anterior chest wall mass is benign. In this patient, the mass is not palpated until 2 years ago. This data does not support the diagnosis of benignity but it also does not negate it.

Thus, in the absence of inflammation and malignancy, and considering benign anterior chest wall neoplasms are more common than malignant ones, my clinical diagnosis, therefore is a benign anterior chest wall mass, right, most likely a myoma or lipoma.

As an added investigation to the anterior chest wall mass, a pertinent question to ask is whether there is a history of previous surgical consult. To this question, the patient underwent attempted excision but to no avail.

The output expected in clinical diagnosis is a rational primary clinical diagnosis. The primary clinical diagnosis is a benign anterior chest wall mass, right, myoma or lipoma. I have presented the bases that made my diagnosis rational.

As to the secondary clinical diagnosis, I will consider a malignant soft tissue mass, probably a sarcoma.

PARACLINICAL DIAGNOSTIC PROCEDURE

Do I need a paraclinical diagnostic procedure? My primary clinical diagnosis is a benign anterior chest wall mass. My secondary clinical diagnosis is a malignant anterior chest wall mass. My basis for choosing benign over malignant is prevalence. That makes my diagnosis not quite certain. Being uncertain, theoretically speaking, I need a paraclinical diagnostic procedure.

The treatment for both primary and secondary diagnosis is operative extirpation. Whether the tumor is benign or malignant, my operative procedure will be extirpation of all gross tumors.

Since my treatment plan and procedure will be the same for both my primary and secondary clinical dignoses, then I decide that I do not need a paraclinical diagnostic procedure.

TREATMENT

My pre-treatment diagnosis is anterior chest wall mass, right, benign. The goal and objective of treatment will be to completely extirpate all grossly evident tumors in such a way that there will be no local recurrence and no complications.

The most cost-effective treatment is an operative extirpation. Drugs are ineffective.

PRE - OPERATIVE PREPARATION

Pre-operatively, I will:

1. Secure an informed consent after I have explained the diagnosis and proposed treatment to the patient and relatives.

2. Provide psychosocial support to allay fear and anxiety.

3. If there is a co-existing disease, optimize the patient's physical health so that he can withstand the operative procedure. In the case of this patient, he has a malignant hypertension unrelieved by the usual antihypertensives. He is being co-managed by the Cardiovascular Section of Medicine who suggests deferral of surgery until the blood pressure normalizes. The patient will be discharged in 2 days and will be on regular follow-up with our service. He is for re-admisson for possible surgery.

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. Caesar Casanova's Case Presentation and Discussion
Dr. Pip Acepcion's Case Presentation and Discussion
Manuscript With Facilitator's Comments
GSI Case Presentation and Discussion
GSI Frontpage