Case Report
A 56-year-old man presented with right-sided pleuritic flank pain, along with a 30-lb weight loss over a 6-month period. A computed tomographic scan revealed a 5.58×3.7-cm cavitary lesion in the right lower lobe with abutment of the posterior chest wall (Figure 1). He underwent biopsy and staging, and was found to be T3N1, with biopsy-proven well-differentiated bronchogenic squamous cell carcinoma. The patient then underwent right lower and middle lobectomy with concomitant en-bloc resection of the posterior portion of ribs 7 to 11, along with mediastinal lymph-node dissection with negative margins. After surgery, he was treated with 4 cycles of adjuvant chemotherapy with cisplatin and docetaxel.
Six months after surgery, the patient began to complain of right-hand pain isolated to the thenar eminence. He also described swelling and significant pain with active or passive movement of the thumb and with relatively mild-to-moderate palpation of the area. The patient reported that the functioning of his thumb deteriorated rapidly over the course of about 1 month. On physical examination, he was neurovascularly intact with no apparent deficit in sensation of his right hand. There was no erythema or overlying skin changes. His right thenar eminence was mildly enlarged as compared with the left, and a firm, focal mass was readily palpated. Range of motion at the metacarpophalangeal joint of the thumb and index finger was limited because of pain. Thumb opposition was markedly limited. After a detailed history and physical examination, we were concerned about possible deep space infection, old hematoma, or possible metastatic disease. Magnetic resonance imaging (MRI) was ordered to evaluate the palpable mass.
Radiographically, localized soft-tissue swelling was present on the palmar surface of the hand obliquely overlying the index finger metacarpal (Figures 2, 3). On MRI, the lesion measured approximately 1.8×3.3 cm and was isointense to slightly hyperintense diffusely with central hyperintensity on T1 images (Figure 4). On T2 and short tau inversion recovery images, the lesion was more strikingly hyperintense and infiltrative in appearance (Figure 5). Postcontrast images showed avid enhancement peripherally, with central nonenhancement consistent with necrosis in the adductor pollicis.
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