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Lipoma in the Clavicular Fossa

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So here's a case that I read not too long ago,

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and I think this really tells you the importance

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of trying to evaluate the brachial plexus.

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So this was a patient that had a fatty mass

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involving the right supraclavicular area.

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And the patient underwent a

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partial resection of this.

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And this mass, which I'm outlining

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right here, was a lipoma.

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So it was a benign fatty lesion.

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So the issue was, it's a lipoma.

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And I think we can all make this diagnosis.

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But really to take things to the next

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level, what the surgeon was concerned

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about was that this lipoma was involving

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the right supraclavicular fossa.

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So when they started to do their

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resection, the surgeon noticed that

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this lipoma was extending pretty deeply.

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And he was concerned that the mass

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was actually involving the brachial

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plexus or in close proximity to it.

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So the reason they got the MRI was not

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for us to say, yes, there's a lipoma.

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What they really wanted to do was

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identify the relationship of the

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lipoma with the brachial plexus.

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Because from a surgical standpoint, that's

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one of the big determining factors whether or

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not this lipoma could be completely resected.

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So, when we look at this mass, I've

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already outlined the lipoma, but

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again, what we have to do is identify

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where the brachial plexus is located.

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So, I'm going to draw my line down

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the middle, and I'm going to compare

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one side to the opposite side.

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So, on the left-hand side, we can see the

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anterior scalene muscle here, then we can

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see the posterior scalene muscle, and then

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we can see the supraclavicular portion of

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the brachial plexus extending through the

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planes of the scalene muscles, and that tells

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us where that brachial plexus is located.

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Now, on the patient's right-hand

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side, what we can actually see is

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that this mass is extending medially.

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And look what it's doing to

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the anterior scalene muscle.

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This mass is extending between the

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plane of the anterior scalene muscle

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and the medial scalene muscle.

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So, we have a little strip of fat

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that's extending between the anterior

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and the middle scalene muscles.

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So, when we see that fat extending into that

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area, all of a sudden we know that the brachial

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plexus is now at risk for involvement.

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When we look at the image in the center, again,

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let's draw a line down the middle, compare

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one side to the other side, anterior scalene,

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middle scalene, there's the brachial plexus,

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and on the patient's right-hand side, there's

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that anterior scalene muscle, there's the middle

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scalene muscle, and we can see that this fat

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has not only extended between the plane

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of the anterior and the middle muscles,

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but look what it's doing to the

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supraclavicular portion of the brachial plexus.

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It's surrounding that brachial

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plexus, and in fact, it's actually

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stretching that brachial plexus.

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And then when we look at the sagittal T1

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weighted image, to get ourselves oriented,

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this is anterior, and this is posterior.

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Here's the top of the lung.

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This is the clavicle that's located

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here, so I'll just put a C there.

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And then here's our subclavian artery,

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so there's our subclavian artery.

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So we can see not only is the mass extending

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deeply, it's extending so deeply that it's

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actually encased the subclavian artery and

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it's completely encased the three cords

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of the brachial plexus that we see here.

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So in summary, what we were able

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to do in this case is confirm the

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diagnosis of a lipomatous lesion.

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So this was a lipoma, but we were able to

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inform the surgeon that this thing is not

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only extending deeply but it's encased in the

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subclavian artery and adjacent to the subclavian

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artery are the cords of the brachial plexus.

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And we can see that this fatty lesion is

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actually encasing and directly involving

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the cords of the brachial plexus.

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And therefore, we directly affected

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how this patient was treated.

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And it really was a relative contraindication for

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complete resection of this benign lesion.

Report

Faculty

Suresh K Mukherji, MD, FACR, MBA

Clinical Professor, University of Illinois & Rutgers University. Faculty, Michigan State University. Director Head & Neck Radiology, ProScan Imaging

Tags

Neuroradiology

MRI

Head and Neck

Brachial Plexus

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