Case Presentation and Discussion
Anterior Chest Wall Mass
Caesar E. Casanova, 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. Caesar Casanova 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. George Repique and Dr. Pip Acepcion . You may want to read this too and compare.
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg Facilitator
Case Presentation
The Patient
The patient is a 50-year-old male from Laguna who came in for a chief complaint of an anterior chest mass on the right of 2 years duration. There is no history of chest pain nor difficulty of breathing.
Physical Examination:
Keep up the habit of putting an illustration of your physical examination findings.
Case Discussion
Clinical Diagnostic Process
The process of managing a patient starts with a physician knowing the chief complaint of the patient. Our patient came in complaining of a slowly growing mass on his right chest of 2 years duration. After extracting this from the patient, we now focus our attention towards the complaint, that is, towards the mass he is complaining of.
I see a bulge on the patient's upper right chest with dimensions of around 15 cm by 12 cm. A diagnosis of a MASS OVER THE RIGHT CHEST was arrived at, at this point. We now ask what is the origin of this specific mass and by its location, we consider the following:
What do you mean by soft tissue, subcutaneous tissue? The prevailing concept of soft tissue includes all the tissues beneath the skin and above the bone and cartilage. Thus, muscle, nerve, blood vessels, and subcutaneous fats are all soft tissues.
The skin overlying the mass was ruled out as the origin since we see no involvement of the skin, no erythema nor wound nor discharge from the skin. Another notable finding which helped us rule out a skin origin is that on further examination, the mass is very mobile and appears to move freely beneath the skin.
The ribs and cartilage as the origin of the mass was also ruled out by the mobility and the consistency of the mass. If it is from the ribs, it would not be as mobile since it will be attached to the ribs and also, I will expect it to be really hard in consistency but the consistency of the mass is non-hard.
At this point, our working impression is a RIGHT ANTERIOR CHEST MASS UNDERNEATH THE SKIN, 15 x 12 cm, nonhard, mobile, with well-defined border, freely movable.
We now have 3 other considerations left that we have to investigate:
If the mass is from the muscle, I would expect it to be less movable when the muscle contracts since if it is within the muscle, the tension of the muscle fibers would fix it in its place. In the patient's case, the mass is mobile even if the chest muscles are contracted.
Our next consideration is a lymph node since the superior portion of the mass is located near the right axilla and as we all know is the location of a lot of lymph nodes. Thus, we are now thinking that it might be a metastatic lymph node. We now investigate the chest to look for a possible primary. We see no other lesion nor any other symptoms which may be connected with any lesion giving rise to a possible axillary lymph node.
I am now left with the soft tissue as a possible origin which I am considering since we know that the mass is beneath the skin, above the bones and cartilages of the ribs but not from the muscle nor lymph nodes. At this point, my impression would be A RIGHT CHEST MASS MOST LIKELY FROM THE SOFT TISSUES.
The work is not finished yet. We now have to be specific regarding the nature of the mass; as to whether is is malignant, non-malignant, or inflammatory.
As to the possibility that it is inflammatory, we would expect it to have an erythematous skin overlying the mass, a tender mass, the skin would be warm to touch, and the patient may have febrile episodes. All these signs and symptoms are absent in our patient. We can now rule out that the mass is inflammatory in nature.
Regarding its possible malignancy, we now consider the characteristics of a malignant lesion. I would expect it to be fixed since there would be invasion of adjacent structures like the ribs, sternum, muscle, skin; that there would be lymph nodes in the right axillary area; that it would be a hard mass; that it would have grown to a large size in a short period of time. The chest mass of the patient does not have any of these characteristics.
Thus, we don't think that it is a malignant lesion. If it's not inflammatory nor malignant in nature, the only other possibility is that it is a benign lesion. Characteristics of a benign lesion include: freely movable with well-defined borders, slowly growing tumor, may be cystic. The mass of the patient is present since 2 years ago and is slowly enlarging without any invasion to nearby structures and thus, there is no fixation. It even has well-defined borders. Although it is not cystic in character, at this point, I am inclined to think of the mass as a benign lesion.
Your claim of a "slowly enlarging mass" is open to question considering the size of 12 cm (that's big!) in 2 years. The most reliable cues for a nonmalignant soft tissue mass are the very well-defined border and FREE MOBILITY OF THE MASS!
I have narrowed down my diagnosis to: BENIGN SOFT TISSUE MASS OF THE RIGHT CHEST. With this, my primary consideration would be a LIPOMA. This is because I am quite confident that the origin of the mass is the soft tissue of the chest and lipoma is one of the common soft tissue masses. A worthy secondary diagnosis is liposarcoma which is a malignant lesion considering the age of the patient and the mass being a solid tumor. And also, soft tissue sarcomas generally present with a painful mass that also gradually enlarges and they tend to invade locally. Among the soft tissue sarcomas, the most common is LIPOSARCOMA.
Why Lipoma? If the mass is at the subcutaneous level and is nonhard mass with well-defined border, most likely it is a lipoma. Use these cues or pattern recognition process first before invoking lipoma as the most common soft tissue masses. The secondary diagnosis is soft tissue sarcoma because soft tissue sarcoma can also present with the features manifested by the patient's mass. Unless you can back it up with good evidence, I don't think liposarcoma is universally accepted as the most common soft tissue sarcoma. Even at the subcutaneous level, liposarcoma may not be the most common. My experience has taught me to just limit the clinical diagnosis to a soft tissue sarcoma without even attempting to determine the specific type. The specific type will have to be provided by a microscopic examination of the tissue.
Paraclinical Diagnostic Process
My pretreatment diagnosis is a lipoma which is a benign lesion and to differentiate it further from a malignant lesion, a biopsy would confirm the diagnosis. It is very important that we differentiate the two since management would be different for the two. We would do a simple excision of the mass if it is a lipoma but we'll do a more extensive excision involving surrounding structures if it turns out to be a liposarcoma.
You forgot to utilize to degree of certainty process or factor. If you are quite certain the mass is a lipoma, then you don't need to have a paraclinical diagnostic procedure, even if your secondary diagnosis is a sarcoma.
Preoperative Care
Preoperatively, we should talk and explain to the patient our plan of treatment and secure a consent for the said procedure. We should do our best to make him feel comfortable and provide support. We should also do a systematic evaluation of the patient to check for any other problems that we can address. We prepare and make sure that the needs for the operation would be available prior to the procedure.
Intraoperative Management
Intraoperatively, we should plan what incision to do taking into consideration the cosmetic effect of the incision and the exposure of the mass using our incision of choice. As the mass is exposed, we do a secondary evaluation of the mass and re-assess our primary diagnosis. Do we proceed or do we change the diagnosis which in effect will change the planned procedure? We inspect and palpate the mass, evaluate the surrounding tissues and see the extent of the lesion. If we see and is confident that the mass is benign, we proceed with total excision, being careful not to involve other tissues but making sure that no lesion is left after the excision. We then inspect the area of the excision for any bleeding and do hemostasis. We also check for any foreign material left inside the excision area like gauze and instruments. We then start closing the wound using a vicryl 4-O subcutaneous suture to avoid the pain of suture removal and the unsightly scars using a non-absorbable simple interrupted suture.
Postoperative Care
Postoperatively, our primary concern is the patient's comfort; thus, we provide analgesics and talk with the patient to reassure them of their condition. Wound should be checked for possible infection. Patient is then adviced on his home and follow-up plans.
After all these, I have achieved a satisfied, alive patient with no complications.
Facilitator's Additional Comments
Take note of the concept of soft tissue tumor and sarcoma.
Look up for reliable cues for soft tissue sarcoma.
Suggestions to Dr. Caesar Casanova 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. George Repique and Dr. Pip Acepcion.
Case Presentation and Discussion Evaluation
Key:
A - Adequate, Acceptable I - Inadequate, Insufficient, Improvement Needed NA - Not applicable, Not assessed
1. Clinical Diagnostic Process
AINA
1.1
Rational Process Using Pattern Recognition and Prevalence
1.2
Specific Diagnosis
2. Paraclinical Diagnostic Process
2.1
Indication Using Degree of Certainty and Whether Management Will Change if the Real Diagnosis Turns Out to be the Secondary Diagnosis
2.2
Cost-effective Selection
2.3
Rational Interpretation
3. Nonsurgical Treatment - Rational
4. Surgical Treatment (Preop)
4.1
Psychosocial Preparations
4.2
Screening for Medical Problems
4.3
Optimizing Physical Conditions
4.4
Preparing for Operating Needs
5. Surgical Treatment (Intraop)
5.1
Rational Intraop Evaluation
5.2
Rational Operative Maneuvers
5.3
Adequate Operative Maneuvers
6. Surgical Treatment (Postop)
6.1
Adequate Postop Care
6.2
Rational Postop Diagnosis
6.3
Rational and Adequate Follow-up
7. Health Promotion and Maintenance
8. Medical Recording
7.1
Adequate and Relevant
7.2
Clear
7.3
Systematic and Organized
9. Discussion in General
8.1
Adequate
8.2
8.3
Reactions from Dr. Caesar Casanova, Jr.
(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.)
Dr. George Repique's Case Presentation and Discussion Dr. Pip Acepcion's Case Presentation and Discussion GSI Case Presentation and Discussion gs1welcome.htm