A combined, supraclavicular, infraclavicular, transaxillary, and posterior subscapular approaches for en bloc resection of giant myxofibrosarcoma

Figures

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  Figure 1:. Preoperative magnetic resonance imaging demonstrating an irregular, large bilobed T1 hypointense (a and b), T2 hyperintense (c-e), heterogeneously enhancing mass (c-e) involving the right chest wall, abutting the brachial plexus, and extending into the right neck.

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  Figure 2:. Intraoperative lateral decubitus positioning demonstrating free mobility of the right arm and exposure of neck and anterior (a) and (b) posterior chest wall. (c) Planned supraclavicular and infraclavicular incisions. (d) Planned axillary and posterior subscapular incisions.

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  Figure 3:. (a) Supraclavicular incision with mass retracted laterally, dissection flap containing spinal accessory nerve, and upper trunk (*blue loop). (b) Infraclavicular exposure with medial cord (yellow loop) lateral cord (*blue loop) and posterior cord (blue loop), and axillary artery (red loop) with underlying mass. (c) Axillary and infraclavicular incisions with proximal and distal brachial plexus exposure including musculocutaneous nerve (*blue loop) and median nerve (blue loop). (d) Posterior subscapular incision with dissection off posterior chest wall and lateral mass retraction. (e) Pathology specimen of gross tumor.

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  Figure 4:. Tumor histology (a) The tumor has high cellularity and severe cytologic atypia (hematoxylin and eosin, ×200 magnification). (b and c) The tumor also had focal areas with loose myxoid stroma and associated delicate vessels (hematoxylin and eosin, ×100 and ×200 magnification. (d) Necrosis was also present (upper left of image; hematoxylin and eosin, ×100 magnification). (e) Mitotic figures were also present (center of image; hematoxylin and eosin, ×400 magnification).