Idelle V. Aschen, MD
PM&R Resident Physician
NewYork-Presbyterian - Cornell/Columbia
New York, New York, United States
Akinpelumi Beckley, MD
Assistant Professor of Rehabilitation and Regenerative Medicine at CUMC
Columbia University Medical Center Department of Rehabilitation and Regenerative Medicine
New York, New York, United States
This patient is a 42-year-old female with history of right-sided inflammatory breast cancer who underwent a modified radical mastectomy with axillary lymph node dissection following neoadjuvant chemotherapy. Patient developed secondary lymphedema in right upper limb after chemotherapy and radiation managed with lymphedema therapy and garments. Over three years later, patient presented with acute right arm heaviness, weakness, and swelling concerning for brachial plexopathy. Physical exam was significant for moderate lymphedema of the arm, forearm, and hand. Strength was 0/5 for shoulder abduction, elbow flexion, elbow extension, wrist extension and 1/5 for finger abduction and flexor digitorum profundus at the 2nd and 5th digit. MRI cervical spine showed mild right C3-4 and mild-to-moderate bilateral C4-5 foraminal stenosis. MRI brachial plexus showed a heterogenous mass in the right anterior chest wall involving multiple plexus divisions concerning for malignancy. Right clavicular region biopsy confirmed moderately differentiated invasive mammary carcinoma consistent with recurrent disease.
Discussions:
The two major causes of brachial plexopathy in breast cancer patients are radiation damage and metastatic involvement of the brachial plexus, so it is important to consider this for all patients presenting with new or worsening symptoms. This can cause pain and disability of the upper extremity impacting a patient's functional outcomes. Early diagnosis provides the best outcomes in treating neuromuscular complications of metastatic cancer, as was demonstrated by this patient having improvement in her distal arm strength after several cycles of treatment.
Conclusions:
Metastasis or local tumor recurrence should be considered in all patients presenting with signs and symptoms of brachial plexopathy, as patients have potential for functional recovery with early diagnosis and treatment.
