A rotator cuff tear causes shoulder pain and limits movement of the shoulder joint. A chronic degenerative change or impingement is the reason for a rotator cuff tear. Diagnosis is made based on medical history and, physical and radiological examinations. Other causes of shoulder pain include calcific tendinitis, degenerative arthropathy, joint dislocation, fracture, and primary or metastatic neoplasm. However, metastatic cancer in the shoulder joint is difficult to diagnosis. We experienced a case in which a 46-year-old female patient complained of left shoulder pain and limited joint mobility, and these symptoms were due to metastatic breast cancer in the shoulder.
Keywords: neoplasm metastasis, rotator cuff, shoulder
Shoulder pain occurs in 6.6 to 25 people out of every 1000, and is the third most frequent musculoskeletal disease after low back pain and knee pain [1 -3 ]. The shoulder joint is the joint with the largest range of motion in the body, and the cause of shoulder pain is not just limited to the shoulder joint but can also be caused by lesions in the surrounding area. Common causes of shoulder pain are rotator cuff pathology, adhesive capsulitis, calcific tendinitis, degenerative joint disease, dislocation, fracture, acute trauma, and tumors [4 ].
The authors have recently experienced a case in which a 46-year-old female patient who complained of left shoulder pain and limitation of motion (LOM). After taking a medical history and giving a physical examination, rotator cuff pathology with accompanied rotator cuff tear was suspected but no abnormalities were seen in the ultrasonography. Through magnetic resonance imaging (MRI) and bone scan, metastatic breast cancer believed to have been completely removed by a previous surgery was observed in the humeral head. Herein, we report a case of metastatic breast cancer in the humeral head of the shoulder joint in a 46-year-old woman along with a literature review.
The 46-year-old female patient visited our department complaining of left shoulder pain that started after frequent use of the arm 1 month prior to her visit. The pain was of a dull nature with a visual analogue scale (VAS) of 35/100 mm and when the left arm was moved, the pain intensified with a VAS of 100/100 mm. She also complained of LOM in the left shoulder joint and disruption in sleep from the pain.
The patient had
been diagnosed with right breast cancer 6 years prior to her visit and had a modified radical mastectomy done. She had been regularly visiting a surgical clinic until recently, was taking tamoxifen every day, had a whole body bone scan and ultrasonography done in the breast area once a year, and PET-CT (Positron Emission Tomography-Computed Tomography) taken once every two years to observe progress, but there were no traces of recurrence or metastasis. In the physical examination, there were no irregularities in the inspection, but there was tenderness in the palpated left greater tuberosity. The LOM in her left shoulder joint during active movement was as follows: 150° flexion and 50° extension from the sagittal plane; 110° abduction, 50° adduction from the coronal plane; 40° external rotation. Regarding the internal rotation to the back, her left hand could reach her 1 st lumbar vertebra. Meanwhile, regarding passive movement, the patient complained of pain between 90 to 120° in abduction, but there was no LOM in any direction. The patient was positive for the Neer test, positive for the empty can test, and positive for the drop arm test; therefore, rotator cuff pathology with accompanied supraspinatus tendon rupture was suspected. Hence, a laboratory examination and simple x-ray was done but there were no abnormalities, and the left shoulder area was examined using an ultrasonography by our department, but the anticipated rotator cuff pathology could not be confirmed. An ultrasound-guided left suprascapular nerve block was done to treat the pain in the shoulder area, but the alleviation of the pain was insignificant. Thus, an ultrasonography was requested to be done by the Department of Radiology, but there were no abnormalities found in the rotator cuff. The patient complained of continuous pain and LOM so an MRI and bone scan were done. In the MRI examination, a cancer lesion could be observed in the humeral head ( Fig. 1 ), and in the bone scan, abnormalities suspected from a metastatic tumor were found in the humeral head and 10th thoracic vertebra. The patient was transferred to the Department of Internal Medicine and was diagnosed with metastatic breast cancer in the humeral head and 10 th thoracic vertebra and received chemotherapy and radiotherapy. Currently, six months later, there are no observations of metastasis into other areas and the cancer lesion in the humeral head has not changed.