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Table of Contents
LETTER TO EDITOR
Year : 2019  |  Volume : 27  |  Issue : 3  |  Page : 160-161

Ultrasound imaging for an uncommon cause of shoulder pain: Metastatic brachial plexopathy in a woman with breast cancer


Department of Physical Medicine and Rehabilitation, Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan

Date of Submission09-Dec-2018
Date of Acceptance06-Mar-2019
Date of Web Publication04-Jun-2019

Correspondence Address:
Dr. Ke-Vin Chang
Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, No. 87, Neijiang Street, Wanhua District, Taipei City 108
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JMU.JMU_120_18

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How to cite this article:
Chang KV, Wu WT. Ultrasound imaging for an uncommon cause of shoulder pain: Metastatic brachial plexopathy in a woman with breast cancer. J Med Ultrasound 2019;27:160-1

How to cite this URL:
Chang KV, Wu WT. Ultrasound imaging for an uncommon cause of shoulder pain: Metastatic brachial plexopathy in a woman with breast cancer. J Med Ultrasound [serial online] 2019 [cited 2022 Aug 10];27:160-1. Available from: http://www.jmuonline.org/text.asp?2019/27/3/160/259736

Dear Editor,

A 42-year-old female had a history of breast cancer. She complained of the left shoulder pain for the past 6 months. She was treated as a frozen shoulder initially in a rehabilitation clinic due to progressively limited shoulder range of motion. Since physical therapy was not helpful, she was referred for a shoulder ultrasound (US) examination. The prescanning physical examination showed only 50% of normal shoulder motion range in all directions and weakness in the shoulder abduction, elbow flexion, and the hand grasping strength. There were no symptoms such as Horner syndrome or paresthesia at her upper extremity. As there was no remarkable US finding of rotator cuffs, the transducer was relocated more proximally to investigate the supraclavicular region. The brachial plexus appeared diffusely swollen in contrast to that at the contralateral side [Figure 1]. The enlarged nerve bundles could be visualized all the way back to the root level. Brachial plexopathy due to cancer metastasis was impressed and later confirmed by the magnetic resonance imaging (MRI). She did not receive a biopsy of the brachial plexus lesion. Subsequent radiochemotherapy was arranged, and she had a significant recovery of shoulder movement and strength 3 months later with concurrent physical therapy (range of motion exercise and shoulder girdle muscle-strengthening). The subsequent US images showed decreased sizes of the previous swollen nerve roots.
Figure 1: Diseased and normal brachial plexus (dashed area) at the supraclavicular (a and b), interscalene (c and d) and cervical root (e and f) levels; SA: Subclavian artery, ICA: Internal carotid artery, TP: Transverse process

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Pain over the shoulder girdles is a common initial presentation of metastatic brachial plexopathy.[1] Pain usually aggravates during shoulder motion due to the stretching of the nerves at the affected region, leading symptoms sometimes mimicking adhesive capsulitis. Weakness and sensory changes conventionally develop over the upper limb innervated by the lower trunk, but the deficit might be trivial at the early stage compared with the intense shoulder pain. Unlike adhesive capsulitis which has an evolution from painful freezing to a nonpainful frozen phase, patients with metastatic brachial plexopathy have progressive pain irresponsive to nonsteroidal anti-inflammatory drugs or physical therapy. In our case, limitation of range of motion in whole directions might result from adhesive capsulitis secondary to persistent shoulder pain. However, long-lasting shoulder pain without response to physical therapy is not a typical presentation of idiopathic adhesive capsulitis. The common cancers that incur metastatic brachial plexopathy comprise lung cancer, breast cancer, and lymphoma.[1] Therefore, in patients with the history of preexisting or on-going malignancy, detailed physical and imaging studies are required to investigate whether the shoulder pain results from metastatic lesions or tumor direct invasion.

The diagnosis of metastatic brachial plexopathy currently relies on MRI or fluorodeoxyglucose (FDG)-positron-emission tomography (PET).[2],[3] A typical lesion on MRI reveals a perineural thickening and enhancement with possible intraspinal extension, whereas it on PET shows abnormal uptake of FDG along the brachial plexus. However, both imaging techniques are expensive and rarely used for screening.

The high-resolution US has emerged as a cost-effective imaging modality to depict peripheral nerve lesions.[4] In our patient, it also helps in confirmation of rotator cuff integrity. In metastatic brachial plexopathy, the tumors diffusely infiltrate the nerve bundles and surrounding sheaths, yielding swollen nerve cords with the loss of inner fibrillary patterns.[4] In contrast, in radiation-induced plexopathy, the size of nerve bundles is usually normal or smaller but with increased perineural connective tissue, which can be used for distinguishing from the metastatic cause.[4] This case highlighted the usefulness of US in differentiating uncommon causes of shoulder pain in patients with a positive cancer history.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

All persons who have made substantial contributions to the work reported in the manuscript (e.g., technical help, writing and editing assistance, and general support) but who do not meet the criteria for authorship are named in the acknowledgments and have given us their written permission to be named. If we have not included acknowledgments in our manuscript then that indicates that we have not received substantial contributions from nonauthors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gwathmey KG. Plexus and peripheral nerve metastasis. Handb Clin Neurol 2018;149:257-79.  Back to cited text no. 1
    
2.
Lapegue F, Faruch-Bilfeld M, Demondion X, Apredoaei C, Bayol MA, Artico H, et al. Ultrasonography of the brachial plexus, normal appearance and practical applications. Diagn Interv Imaging 2014;95:259-75.  Back to cited text no. 2
    
3.
Gandhi SJ, Rabadiya B. Metastatic brachial plexopathy with brain and spinal metastasis in a case of recurrent breast carcinoma demonstrated on 18F-FDG PET/CT. Indian J Nucl Med 2017;32:118-21.  Back to cited text no. 3
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4.
Martinoli C, Gandolfo N, Perez MM, Klauser A, Palmieri F, Padua L, et al. Brachial plexus and nerves about the shoulder. Semin Musculoskelet Radiol 2010;14:523-46.  Back to cited text no. 4
    


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