A 38-year-old woman presented to the outpatient Pulmonary Clinic at the Penn State College of Medicine in Hershey, Pa, complaining of chronic pain in her upper arm and shoulder on the right side.
The patient reported that while she was at work 3 years earlier, a forklift trapped her right upper arm and shoulder against a wall, resulting in immediate and persistent numbness and tingling in the right hand. Initial surgical treatment included decompression of the right radial nerve and cervical spinal fusion of vertebrae C4 through C7. However, chronic, unrelenting pain persisted. The patient therefore sought neurosurgical consultation for possible brachial plexus surgery. The neurosurgeon ordered a thoracic CT scan, the results of which revealed a right apical pleural-based lesion.
The neurosurgeon referred the patient to a community pulmonary specialist, who monitored the lesion. In 1 year, the lesion grew from 1.5 cm × 1.2 cm to 1.6 cm × 1.4 cm. A positron emission tomography (PET) scan confirmed the presence of a right apical pleural-based nodule. The pulmonologist suspected a malignant primary lung mass and referred the patient to an osteopathic physician (M.G.B.) at the Penn State College of Medicine.
The patient denied fever, chills, night sweats, and weight loss. She also stated that she did not have chest pain, shortness of breath, cough, wheezing, or hemoptysis. She had no history of seasonal or perennial postnasal drip, rhinitis, sinusitis, asthma, bronchitis, or pneumonia. She had intermittent headaches but no history of seizures or skin lesions. The patient had no history of alcohol or drug abuse, and though she never smoked cigarettes, she had exposure to secondhand smoke from both parents throughout childhood. Before the work injury, which left her disabled, she had worked as a laborer in a battery factory for 6 years, and before that, in a fabric factory. The patient also reported that she had consistently received age-appropriate preventive health screening.
On physical examination, the patient's blood pressure was 120/84 mm Hg; heart rate, 72 beats per minute; respiratory rate, 16 breaths per minute; and body mass index, 30. She appeared healthy and in no distress, with neither cervical nor axillary adenopathy. Cardiovascular examination revealed a regular heart rate without murmurs. Her lungs were clear to auscultation with normal percussion notes and no point tenderness with chest wall compression. Chest excursion and diaphragm descent were normal. The patient's fingernails were normal, her fingers were not clubbed, and she had no peripheral edema or skin or joint lesions. The results of her neurologic examination were normal except for 4/5 muscle strength in right shoulder abduction and diminished sensation on the palmar aspect of the medial two fingers on her right hand.
The initial CT scan showed a focal area of nodular thickening measuring 60 Hounsfield units—similar to the density of muscle—located in the lateral right apical lung pleura. There were no other lung or pleural-based masses, no mediastinal, hilar, or axillary adenopathy, and no pleural effusion. The heart and great vessels were normal, as were the postsurgical changes from the spinal fusion.
A second CT scan 3 months later revealed an increase in lesion size. A PET scan taken immediately afterward showed a single 1 cm × 2 cm FDG-avid lesion at the same location. Three core biopsies under CT guidance yielded benign, CD31-positive tissue, which is consistent with lymphangioma (
Figure 1).
4 A CT scan with intravenous contrast administered to the right antecubital fossa showed no evidence of structural compression to right apical lymphatic flow (
Figure 2).
The patient returned for a third CT scan 3 months later, at which point the lymphangioma measured 1.3 cm × 2.2 cm between the lateral aspect of the second and third ribs on the right side. Minimal dependent bibasilar atelectasis was present. The bony structures were otherwise unremarkable, and no right shoulder mass was seen on the margin of the images.
The patient's condition was presented to the multidisciplinary thoracic tumor conference group at the Penn State College of Medicine. The lymphangioma was extra-pulmonary and was determined to be an unlikely source of the patient's chronic pain. Because no vital structures were obstructed, the lesion was not excised. However, as consensus dictated at the conference meeting, the patient continues to receive follow-up CT scans for serial observation of the lesion. Gabapentin, prescribed by the patient's family physician, alleviated her chronic arm and shoulder pain, though the source of that pain was not found.