A 56-year-old man, a taxi driver, with no previously identified medical history except for overweigh.
The patient presented to consultation with a deforming, large tumor in the right armpit, asymptomatic, but that had suffered a gradual and painless increase in volume, more pronounced in a short period of time until his dominant limb activity could develop.
In the clinical interview it was documented that the evolution of the mass, with a constant development, had progressed without interference of infection, trauma, medical treatments, or presence of other types of tumors contributing to the anatomic drainage area.
The patient reported that, originally, the tumor grew slowly and gradually for approximately 6 to 9 months, until it grew rapidly in the last 2 months of evolution, deforming the right internal thoracic fold and the lateral chest wall.
In the clinical examination we identified absence of affectation of the possible anatomical nerves involved in the region, which led us to a suprafascial location of the tumor.
We found no damage to the lateral thoracic innervation of dermatomes corresponding to the 26 intercostal nerves region related to the corresponding peripheral level in relation to the nipple areola complex (CAP) and the wall.
No alteration of the medial surface of the arm or lateral chest wall was found, territory innervated simultaneously by the intercostobrachyal nerve that was not affected.
The patient also reported that at no time presented secretion by the nipple or underlying growth that would guide breast pathology, but it was evident in the examination marked and lateralized dislocation of the tumor mass related to growth of the NAC.
When the mass was fixed, it was soft and deformable to manual pressure. A possible positive liquid wave was detected, which was not very clear in the evaluation due to the large adipose panniculus presented by the patient.
Apparently, it was not adhered to superficial tissues and hardly adhered to the deep plane, clearly due to its easy mobilization between the anatomical structures involved.
We requested diagnostic imaging tests: CT and ultrasound, and it was indicated to return to the consultation once performed for study and evaluation.
Three weeks later, the patient returned to the clinic presenting a greater growth of the axillary mass that already affected a large part of the lateral chest wall and adjacent thoracic territories, both anteriorly and posteriorly.
The diagnostic tests requested had not been performed due to lack of economic resources, which had not been reported to us at the time.
The patient continued without presenting or reporting weight loss or associated intrathoracic changes that could guide us to think about some specific type of tumor pathology.
At this time, with a 9-month evolution, the dimensions of the axillary mass were 25 x 20 cm in its external presentation, without evident alterations in the skin cover and with the same clinical characteristics and lack of associated symptoms.
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Given the lack of resources and the evolutionary characteristics of the lesion, we chose to perform diagnostic tests and refer the patient again to the Department of Diagnostic Imaging.
Ultrasound with a surface transducer confirmed the cystic condition of the tumor mass, and revealed its anatomical relationship with adjacent risk structures.
The CT scan showed the presence of a cystic, bilobulated mass in the right axillary hollow, with dimensions of 15.7 x 15.1 cm in diameter, displacing the adjacent muscle structures, with no evidence of alteration in the vascular structures.
Both diagnostic methods contributed in a sufficient way to demonstrate the complexity of the dissection required for surgical removal of the tumor, and objectively showed that it was a peripheric cystic mass with characteristics of a non-circulating benign tumor, not lo
The cystic mass, in its transversal diameter of growth, extended from below the pectoral muscle that appeared displaced anteriorly to the dorsal muscle width that was posteriorly displaced, and was completely identified in a muscular wall.
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The surgical intervention for its removal was carried out under general anesthesia and previous peritumor instability with blunt tip cannula and lateral orifices of local anesthetic with vasoconstrictor.
The dissection plane was carefully identified, with a preferentially intraosseous approach in almost the entire tumor periphery that minimized bleeding during dissection, maintaining the integrity of the tumor capsule.
Peritumoral margins were gradually identified during dissection, well-defined in almost all of its surface except in the medial walls and ceftaphate, which were considered to be a possible recurrence. The possibility of filling an axillary cystic mass was then confirmed.
The moment of greatest intraoperative risk was that of the filling approach of the cystic mass with the tumor towards the axillary hollow, corresponding to the location of the possible lymphatic vessels nutrients of the cystic mass, which was found to be impossible new lateral t-shaped sutures.
No lymphadenopathy suggestive of lymph node tumor pathology related to obstruction of the tumor efferent pathway was found.
Its immediate contiguity with adjacent vessels and nerves was carefully dissected to isolate them from the subclavian and axillary neurovascular structures.
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Due to the large cavity resulting as a defect after complete removal of the tumor, measuring 25 x 20 cm, we used obliterating sutures between the superficial and deep anatomical planes dissected in a way that did not considerably reduce the resulting bleeding.
As a necessary precaution, three drainages were left with suction and we performed a closure by internal planes, in addition to a rapid cutaneous closure with surgical staples and a compressive dressing that helped obliterate the cavity
Total operative time was 2 hours and 15 minutes.
The surgical area and suction drains were reviewed the day after the intervention, which showed ambulatory conditions manageable to proceed with the patient's hospital stay.
Seven days after surgery, the skin staples were removed and aspiration drainages were maintained until a low output was achieved, which occurred 10 days after the intervention.
The pathology report was a resected mass of 2.7 kg of weight (already in formalin), with morphology of cystic cavity non-loculated and without septa inside, intactly dissected, with capsule content of mature lymphocytes.
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After 3 months of postoperative evolution, the patient had no functional disability and could return to his usual professional activity.
After a 10-month follow-up, no signs or symptoms of tumor recurrence were observed.
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The resolution of the case with the surgical intervention and the care applied was satisfactory and complete.
In the surgical procedure, we believe that it was crucial to fully identify the filling lymphatic vessels, which were properly connected, and that which was determined intraoperatively that they came for filling exclusively the chest wall.
