American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Subcutaneous Lesion in an Oncologic Patient

The lower panel demonstrates the lesion in the supraclavicular area on conventional ultrasonography. Encapsulated cystic lesion with hyperechogenic areas inside being in constant movement. The upper panel shows largely decreased elasticity of the peripheral part of the lesion on sonoelastographic examination.

The lower panel demonstrates the lesion in the supraclavicular area on conventional ultrasonography. Encapsulated cystic lesion with hyperechogenic areas inside being in constant movement. The upper panel shows largely decreased elasticity of the peripheral part of the lesion on sonoelastographic examination.

A 40-year-old Caucasian woman presented to our university hospital after she noticed a mass in the right supraclavicular area. The lump was easily palpable, sized 1-1.5 cm, firm, and rather immovable, with surrounding edema (Figure 1). She had noticed the lesion approximately 2 weeks earlier, and during that time the mass was gradually enlarging. Her personal history revealed combined therapy for breast cancer and surgical removal of thymoma at age 23 years, as well as nontoxic nodular goiter, whereas family history revealed thyroid cancer in her mother. Therefore, an initial diagnosis was a lymph node metastasis, with the most probable primary sites in the breast or the thyroid.

Six years earlier the patient underwent quadrantectomy of the left breast and the removal of axillary sentinel lymph node due to breast cancer at age 34 years (June 2010), followed by high-dose-rate brachytherapy to the tumor bed (July 2010-February 2011). In February 2014 she underwent re-quadrantectomy of the breast owing to recurrence of the disease and lymphadenectomy of the left axilla in December 2015. Histopathologic examination revealed metastases to 16 of 23 resected lymph nodes, the largest being 2.1 cm, and infiltration of the fat tissue. Subsequently, 4 cycles of adjuvant chemotherapy (cyclophosphamide and doxorubicin) and 12 cycles of paclitaxel (January 2015-June 2016) were scheduled. Immunohistochemical examination revealed the presence of estrogen and progesterone receptors in >75% of the tumor cell nuclei. Cells were HER2 negative, and expression of Ki67 was found in 40% of cell nuclei. She also took hormonotherapy from July 2010 to November 2015 (tamoxifen) and from June 2016 (gosereline and exemestanum). From July 2016 to August 2016 she received 6-MV intensity modulated radiation therapy for regional supraclavicular lymph nodes and left axilla (50 Gy/T).

Assessment

Thyroid ultrasound revealed a gland of typical localization and size (right lobe 23 × 14 × 49 mm, containing an anechogenic lesion sized 3 × 2 × 3 mm and isoechogenic lesion sized 4 × 3 × 4 mm; left lobe 22 × 15 × 48 mm, containing a 5 × 5 × 6-mm mixed solid/cystic lesion). Lesions were found to be benign on fine-needle aspiration biopsy 2 years before, and no size progression was observed since then. Ultrasound examination of the mass in the right supraclavicular area revealed an encapsulated solitary cystic lesion of 12 × 7 × 11 mm located subcutaneously. The content was predominantly anechogenic but also contained multiple hyperehogenic areas. The mass was not richly vascularized on Doppler examination but demonstrated largely decreased elasticity on sonoelastography (Figure 2), suggesting an inflammatory infiltration or neoplastic change.1 Most surprising, the hyperechogenic objects were moving rapidly within the cyst, suggestive of parasitic infection. We learned that during the summer of 2016 the patient was once severely bitten by mosquitoes. The peripheral blood examination revealed mild eosinophilia (6.3%-8% in a differential leukocyte count), further supporting the possibility of parasitic infestation. No history of travel abroad in the last years proved that the infection was locally acquired.

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-Ewelina Szczepanek-Parulska, MD, PhD, Matylda Kludkowska, PhD, Lukasz Pielok, MD, PhD, Jerzy Stefaniak, MD, PhD, Marek Ruchala, MD, PhD

This article originally appeared in the July 2017 issue of The American Journal of Medicine.

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