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707 - Subpectoral lymphocele presenting as atypical unilateral shoulder pain

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

CH

Colton Higuera, DO

Resident Physician
University of Kansas
Kansas City, Kansas, United States

Co-Author(s)

KM

Kenneth Miller, MD

Physician
Kansas City VA
Overland Park, Kansas, United States
ND

Naga Harshita Degala, MD

Clinical Research Assistant
University of Missouri-Kansas City School of Medicine
Kansas City, Missouri, United States

Case Diagnosis: Right subpectoral lymphocele

Case Description: A 51-year-old male without significant medical history, presented with 9 months of non-traumatic right shoulder pain and decreased overhead range of motion that was unresponsive to conservative management with NSAIDS, and physical therapy. Physical exam was significant for impingement signs and a nontender, fluctuant anterior chest wall mass without overlying erythema or warmth. Subsequent imaging with US, CT, and MRI revealed a simple 10 x 9 x 4 cm subpectoral cystic mass without vascular flow. The patient subsequently underwent image-guided percutaneous aspiration of the collection followed by sclerotherapy. Cytology demonstrated small lymphocytes consistent with a thoracic lymphocele. The patient initially had improvement of symptoms, but shortly thereafter returned with worsening pain and swelling. Repeat imaging confirmed fluid reaccumulation. Interventional radiology recommended that multiple rounds of sclerotherapy may be required for full resolution of symptoms.

Discussions: Lymphoceles typically occur post-pelvic or retroperitoneal surgery, with a 1-20% incidence after renal transplants and >25% post-pelvic lymph node dissection. Subpectoral lymphoceles are rare without trauma or surgery and can mimic musculoskeletal or neurologic pain. Lymphoceles >5 cm often cause symptoms by compressing nearby structures. In this case, it likely contributed to shoulder pain resembling subacromial impingement. Diagnosis requires ultrasound, CT, or MRI, with differentials including soft tissue tumors, abscesses, seromas, hydatid cysts and thoracic outlet syndrome. Management involves percutaneous aspiration with sclerotherapy. Large lymphoceles can recur in up to 50% of cases, and multiple sclerotherapy treatments can reduce recurrence to 10-15%. Refractory cases may require surgery.  

Conclusions: This case highlights the importance of including space-occupying cysts in the differential diagnosis of shoulder pain particularly when symptoms persist despite conservative treatment. 