Question:

A 34 year-old female presents to the ED with worsening left upper extremity pain and weakness. She has a past medical history of neurofibromatosis 1. On exam, she has decreased use of her left deltoid, biceps, triceps, and wrist flexion and extension. She endorses paresthesias. What do you see on her left shoulder radiograph?

Answer:

This female was diagnosed with a malignant nerve sheath tumor encroaching the brachial plexus.

The CT scan demonstrates a large, firm mass, approximately 16cm x 10cm over the upper left aspect of the chest, located immediately below the clavicle. The MRI is of the left brachial plexus. It shows an enhancing and centrally necrotic mass at the left upper chest/ axilla. There is surrounding edema.

The patient was seen by orthopedic surgery. After discussion at a sarcoma tumor board, she underwent surgical intervention with a forequarter amputation. It was recommended that the patient undergo adjuvant chemotherapy after surgery. The patient was amenable to the plan due to lack of arm function and the high risk of metastatic spread without having operative intervention. ■