Phrenic nerve palsy due to sternal and mediastinal breast metastasis

There is new elevation of the left hemidiaphragm since the previous CXR 3 months earlier. This is associated with mild passive atelectasis in the left base and a small left pleural effusion. The remainder of the left lung is clear, as is the right lung. No right pleural effusion. The left hilum appears stable when compared to the previous chest x-ray. Left mastectomy noted. No destructive osseous lesion appreciated. Cholecystectomy clips.

Conclusion

New elevation of the left hemidiaphragm, in this clinical setting (previous breast cancer) this requires further evaluation with CT chest to exclude malignant paralysis of the left phrenic nerve.

A soft tissue mass is centered at the posterior margin of the left second costal cartilage, eroding the manubrium and extending into the prevascular anterior mediastinum. The lesion causes occlusion of the left brachiocephalic vein within the mediastinum, with resultant thrombosis of the left brachio-cephalic and subclavian veins which would account for the left chest wall and arm swelling. The lesion is located at the expected course of the left phrenic nerve which would account for the new finding of an elevated left hemidiaphragm.

There are multiple small prevascular para-aortic lymph nodes and a 20 mm right anterior prevascular lymph node.

A small left pleural effusion is present. No suspicious pulmonary parenchymal nodule or mass.

Whilst the ribs and thoracic spine have a relatively patchy in appearance, no additional destructive skeletal lesion is seen.

Somewhat spiculated soft tissue stranding overlying the left pectoral region may relate to postsurgical changes however, localized soft tissue recurrence is also not excluded.

Conclusion

• Invasive soft tissue mass centered on the second left costal cartilage, manubrium and superior mediastinum with associated left phrenic nerve palsy. In this clinical context most likely metastatic in nature.
• Probable secondary left brachiocephalic and subclavian vein thrombosis - US recommended (which it did)
• Possible soft tissue recurrence left inferior pectoral region at the site of prior mastectomy.